Dental insurance helps you pay for dental work ranging from preventive care to major restorative work. Sometimes it also covers orthodontics.
How dental insurance works
When shopping for dental insurance, you'll want to pay special attention to the following components:
- Premiums
- Deductibles
- Coinsurance and copays
- Waiting periods
- Annual maximums or limits
- Coverage categories and exclusions
- Networks
Note: Dental plans usually provide a plan summary or plan brochure that walks through the details of how these components apply.
Premiums
With dental insurance, you typically pay a monthly premium. The premium will depend on the insurance company, where you live, the number of people you are covering, and the coverage details of the plan you choose.
Deductibles
The annual deductible is the amount a plan requires you to pay before the insurance company starts paying. Most dental plans have separate deductibles for individuals and families. Sometimes dental plans will cover some services like exams without you having to pay a deductible.
Coinsurance and copays
Once a dental deductible is met, most policies only cover a percentage of the remaining costs. The percentage you are responsible for is referred to as coinsurance. In some plans, coinsurance is replaced with fixed rates called copays.
Coverage categories and exclusions
Most dental insurance policies group covered services into three categories: Preventive, Basic, and Major.
Preventive services usually include exams, X-rays, and cleanings.
Basic services usually include fillings, root canals, and extractions
Major services usually include bridges, crowns, and dentures.
Note: Some plans define these categories differently. For example, some plans treat X-rays as basic services and fillings as major services. Also, some dental plans do not cover composite fillings on back teeth (molars), but if you or your dentist prefers composite fillings, that plan will usually cover its share up to the cost of an amalgam filling, and you are responsible for the difference. To avoid a surprise bill, make sure you understand how your plan defines each category of coverage and the services within them.
Some dental policies also provide coverage for Orthodontics.
Orthodontic services include space maintainers, braces, and other devices used to align your teeth.
Most dental insurance policies do not provide coverage for Cosmetics.
Cosmetic services include teeth whitening, tooth shaping, veneers, and gum contouring.
Note: Most dental plans follow a "100-80-50" coverage structure that pays 100 percent of preventive services, 80 percent of basic services, and 50 percent of major services. Orthodontic and cosmetic services are usually excluded.
Waiting periods
Most dental plans require you to satisfy a waiting period before they will cover expensive procedures. During these waiting periods, the insurance company won't cover specific procedures. The idea is to discourage people from gaming the system by waiting to pay for coverage until they need expensive treatments.
These waiting periods vary by coverage category and range from six to 18 months. Sometimes they can be as long as 24 or 36 months for major services and orthodontic services.
Some plans don't require any waiting periods at all. Instead, they offer reduced coverage rates in the first year and step up the coverage rates in years two and three.
Note: Some dental plans will waive certain waiting periods if you can prove you've had prior dental coverage for at least 12 consecutive months.
Annual maximums or limits
A dental plan's annual maximum or "limit" is the most it will pay for your dental care in a plan year. Once you hit the annual maximum, the plan won't cover any more services that year, and you're responsible for any additional costs until the current plan year ends, and a new one begins.
Annual maximums typically range from $1,000 to $2,000. Some dental plans allow you to roll over unused annual maximums to the next year.
Note: Work with your dentist to stay within your plan's annual maximum. You may be able to set up a treatment plan that spreads services over multiple plan years.
Networks
Most dental plans come with a network of preferred dentists and negotiated rates. The way the network works depends on the plan. The most common types of plans are HMO, PPO, and Indemnity.
HMO plans include a provider network with negotiated rates but don't provide any coverage for out-of-network providers. HMO stands for "health maintenance organization".
PPO plans include a preferred provider network with negotiated rates. You're allowed to see an out-of-network provider, but the plan won't cover as much of your costs if you do. PPO stands for "preferred provider organization".
Indemnity plans don't include a provider network and allow you to see any dentist.
Note: Generally speaking, the more dentists you can choose from, the higher the monthly premiums. If you can find an HMO plan that covers your dentists, you can save money on premiums.
Where you can buy dental insurance
There are four ways to secure dental insurance:
- Via an employer group plan
- Via a government program
- Via an individual and family health plan that also covers dental
- Via a standalone individual and family dental plan you buy on your own
Buying dental insurance through an employer group dental plan
The most common way to buy dental insurance is through an employer group. Employer dental plans often provide coverage at lower costs than what you can get on your own. The downside is that your preferred dentist may not be covered by the group plan.
Getting dental insurance through a government program
The U.S. government provides health insurance to more than one-third of Americans and many of those programs also provide dental coverage. For example, Utah Medicaid covers many dental services.
Getting dental insurance through an individual or family health insurance plan that covers dental
Some individual and family health insurance plans also provide coverage for dental services.
Buying a standalone individual or family dental insurance plan
You can also buy a standalone individual or family dental plan on your own. You can purchase these plans via your State Marketplace (we refer to these as "on-marketplace" dental plans) or directly from an insurance company (we refer to these as "off-marketplace" dental plans).
There's one restriction to be aware of for on-marketplace plans. You can only buy an on-marketplace dental plan if you’re also buying an on-marketplace individual and family plan at the same time.
Note: A third-party insurance agent like LegUp Health can help you and your family find, use, and manage on-marketplace and off-marketplace dental plans at no cost to you. Most dental insurance companies pay agents to help you.
How to buy dental insurance
I recommend the following 6-step process for buying dental insurance:
- Confirm your preferred dentist.
- Ask your dentist for a list of dental insurance companies they accept and prefer.
- List out your available options.
- Confirm you understand how the coverage works for each plan.
- Pick the plan that provides the best coverage at the best price.
- Before your buy, compare your cash pay options.
Step 1 — Confirm your preferred dentist.
If you don’t have a dentist, keep in mind that most dental plans come with a provider network that will limit your choices. In my opinion, it's best to pick a dentist before you shop for insurance so you can make sure he or she is in the network.
Step 2 — Ask your dentist for a list of dental insurance companies they accept and prefer.
Contact your dentist and ask which dental policies they accept and prefer to work with. Be sure to confirm the specific network they accept. Some dental insurance companies have multiple networks. For example, Dental Select has a Gold network and Platinum network, and EMI Health has an Advantage network and a Premier network.
Step 3 — List out your available options.
Gather all of your available options. If you have a group dental plan available through your or a spouse's employer, include it in the list. Also, review your individual or family health plan to see if it covers dental and include it if it does. Finally, if you're eligible for a government health program that covers dental, add it to the list too.
Note: If you really like a plan and you're not attached to your dentist, consider switching dentists. For example, if you're eligible for Medicaid, you might want to switch to a dentist who accepts Medicaid.
Step 4 — Confirm you understand how the coverage works for each plan.
Be sure you’re aware of which costs the policy covers and how much you’ll have to pay out of pocket. I recommend making sure you understand the following for each plan to avoid a surprise billing situation:
- Annual deductible(s).
- Annual maximum(s).
- Coverage category definitions, coverage rates, waiting periods, and exclusions.
- Coverage differences for adults versus children.
- Network rules.
Note: If you already have dental coverage, it might be best to keep the same plan so you avoid restarting your waiting periods. That, or you might want to make sure you look at plans that will waive your waiting period.
Step 5 — Pick the plan that provides the best coverage at the best price.
Once you understand the details from the previous step, you should be able to make a confident decision based on your expected dental expenses, risk tolerance, and budget.
Step 6 — Before your buy, compare your cash pay options.
In the years you only need preventive dental services, you often lose money on dental insurance. But in a year you require basic or major dental services, dental insurance can save you money.
Sometimes it makes more sense to pay cash for dental services instead of buying dental insurance. With this approach, you save the money you would have paid towards monthly premiums and pay cash out of pocket when you visit the dentist.
Note: If you decide to go the cash pay route, consider three money-saving approaches. First, look into setting up a health savings account (HSA) so you can pay with pre-tax dollars. Second, talk to your dentist about a direct subscription. Many dentists offer discounted service subscriptions to clients who are willing to pay for multiple cleanings in advance. Third, ask your dentist if they participate in any third-party dental "discount" or "savings" programs. These programs can unlock discounts on commons services for a low monthly fee.
Individual and family dental health insurance options in Utah
Companies offering on-marketplace dental insurance in Utah
EMI Health (Most Popular for LegUp Health clients)
Companies offering off-marketplace dental insurance in Utah
Dental Select (Most Popular for LegUp Health clients)
Independence American Insurance Company
Frequently asked questions
Can you get dental insurance without a waiting period?
Yes. Some dental plans don't require any waiting periods at all. Instead, they offer reduced coverage rates in the first year and increase the coverage rates in years two and three. And some plans will even waive waiting periods if you can prove you've had prior dental coverage for at least 12 consecutive months.
What are the common dental procedures and costs?
According to whydental.org, 95 percent of all dental procedures submitted to insurance fall within 13 general service categories:
- Oral Examinations
- X-rays
- Tooth cleanings
- Fluoride
- Sealants
- Fillings (either amalgam or composite)
- Crowns
- Root canals
- Treatments for gum disease
- Extractions
- Emergency relief of pain
- Anesthesia
- Consultations
You can look up costs for specific procedures using this tool from FAIR Health.
Why do most Utah on-marketplace dental plans exclude basic and major services for children?
Dental is an “essential health benefit” for children under age 19. This means dental insurance companies are not allowed to place annual or lifetime limits on pediatric dental services. In Utah, on-marketplace dental plans are only required to cover cleanings and sealants for children. Some Utah dental insurance companies avoid having to offer unlimited coverage to children for basic and major services by excluding those service categories altogether. Exclusions do not violate the annual or lifetime limits requirements.
What is the best way to avoid a surprise dental bill?
One way to avoid a surprise bill is to request a treatment plan from your dentist before receiving treatment. The treatment plan should include the estimated cost for their dental work. You can then send this treatment plan to your dental insurance company to see exactly how much your insurance will pay.
