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Common Dental Insurance Terms Explained in Plain English

The basic idea of dental insurance is pretty simple. A dental insurance policy helps pay for your dental bills. But the specific details can be very complicated. One major reason dental insurance can feel confusing is because of the language used.

The world of dental insurance is filled with legalese and other technical terms. But there’s no need to feel intimidated. Here’s a complete guide to common dental insurance words and concepts:

Premiums

This is simply the amount of money paid each month to the insurance company for coverage. If you have an individual plan, or even with many employer-provided plans, you pay the premium each month out of your own pocket. In some rare cases, your premiums might be paid by an employer. Insurance coverage will lapse if premiums aren’t paid in time.

Deductible

A deductible is the amount you pay for dental care before insurance will cover the remaining balance. For example, imagine you have a $100 deductible and need a dental procedure which costs $150. Dental insurance will only pay out $50. You’re responsible for paying the rest of the bill.

Out Of Pocket

Not all dental procedures are covered equally by dental insurance policies. While the specifics will vary, generally plans offer “100-80-50” coverage -which refers to how much coverage you get for specific procedures.

Preventative care is usually covered up to 100%. These are procedures designed to identify and prevent dental problems. Common preventative procedures include regular annual exams, x-rays and cleanings.

Basic services are covered up to 80%. These are routine dental procedures such as fillings, extractions, certain types of deep cleanings and uncomplicated root canal treatments.

Major services are covered up to 50%. These are complex procedures such as denture fittings, crowns, bridges and oral surgeries. Major procedures might require multiple visits to the dentist’s office.

Be aware that specific dental insurance plans may cover treatment costs differently. The above is the typical breakdown, but check plan details for the specific out-of-pocket costs for the dental insurance you’re considering purchasing.

Copay and Coinsurance

If your dental insurance has a Copayment, you pay a set amount for a specific dental treatment. HMO plans typically are copayment plans. With coinsurance, you pay a percentage of the cost of your dental care after you’ve met your annual deductible.

Annual Maximum

Dental insurance doesn’t provide unlimited coverage. Your annual maximum is the total dollar amount of coverage provided by the policy each year. An annual maximum is also referred to as an annual cap or annual spending limit.

Annual maximums will vary by policy – but they can be surprisingly low. The average limit is between $1,000 and $1,500. While that’s enough for two cleanings a year and maybe a basic procedure or two, you’ll likely hit that limit quickly if you have major dental needs. Once the limit is reached, your dental insurance won’t cover any other dental care for the rest of the year.

Pre-Existing Conditions

These are certain dental issues you had before you enrolled in a dental insurance plan. Different policies will place different types of restriction on pre-existing conditions. Typically, issues like restoring teeth that were lost before you purchased dental insurance are usually not covered at all, and you’ll have to pay the total cost of treatment out of pocket.

Coverage for restorative dental care – such as crowns, bridges or dentures –  is often restricted by waiting periods ranging from six months to a year. It may seem unfair, but you can understand why insurance companies don’t want people to sign up, pay for a single month of coverage, undergo a ton of expensive dental work and then drop the policy. Waiting periods are designed as a type of protection for insurance providers.

DHMO Dental Plans

Have you ever heard of an HMO? A DHMO has a similar structure. A Dental Health Maintenance Organization provides what’s called “managed care.” If you have a DHMO, coverage is provided through a network of dentists and dental specialists. You can choose whatever in-network dentist you like. Out-of-network dentists are typically not covered by your DHMO.

PPO Dental Plans

An alternative to a DHMO is a Preferred Provider Organization. Similar to a DHMO, a PPO is also a network of participating dental professionals all covered by a single plan. The main difference is size. PPOs generally have a larger network of providers with a broader range of specialties. Plus, PPOs are usually more flexible regarding out-of-network care. Generally, DHMOs have less flexibility but lower costs compared to a PPO.

Indemnity Dental Plans

These are often referred to as traditional dental insurance plans. Instead of a network, you’re free to visit any dentist you like. However, you must also pay the bill in full out of pocket. Then you submit a claim with your insurance company. They’ll reimburse you according to the specifics of your policy. You might have to wait a while for reimbursement. Plus, coverage limits, annual maximums and other restrictions will likely apply.

Dental Discount Plans

Dental discount plans are a different way to pay for dental care. Often called the affordable alternative to dental insurance, an  Aetna dental discount plan offers savings at over 100,000 participating dentists nationwide. Members can save between 15% and 50% on a variety of dental procedures including preventative, basic and major treatments – and many plans cover cosmetic treatments and dental implants, which are typically not covered by dental insurance.

Dental discount plans have no restrictions on annual use. You simply present your membership card directly at the dentist’s office for instant savings on eligible procedures. Plus, discount plans often provide savings on procedures dental insurance won’t cover, such as cosmetic procedures and procedures involving dental problems you had before you purchased the plan.

Final Thoughts

Don’t be intimidated by dental insurance jargon. Many of the terms used actually describe very simple concepts. Whether you choose dental insurance or an Aetna dental plan, don’t be afraid to ask questions until you’re sure you’ve found a plan that fits your needs.

Dental insurance terms can be a mouthful, but you can still afford a beautiful, healthy smile!

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