Insurance FAQ’s


My dentist recommends a treatment that my plan will not pay for. Does this mean the treatment really isn’t necessary?

It is common for dental plans to exclude treatment that is covered under the company’s medical plan. Some plans, however, go on to exclude or discourage necessary dental treatment such as sealants, pre-existing conditions, adult orthodontics, specialist referrals and other dental needs. Some also exclude treatment by family members. Patients need to be aware of the exclusions and limitations in their dental plan but should not let those factors determine their treatment decisions.

My dentist recommends that I get a crown on a tooth, but my dental benefit will only pay for a large filling for that tooth. Which treatment should I have?

Some plans will only provide the level of benefit allowed for the least expensive way to treat a dental need, regardless of the decision made by you and your dentist as to the best treatment. Sometimes, special circumstances may be explained to the third-party payer to request an adjustment to this lower benefit allowance, but there is no guarantee that the third-party payer will alter its coverage. As in the case of exclusions, patients should base treatment decisions on their dental needs, not on their dental benefit plan.

My dental plan says that it will pay 100 percent for two dental checkups and cleanings each year. However, I just had my first checkup and cleaning, and the insurance company says I owe for part of the dentist’s charge. How can this be?

Plans that describe benefits in terms of percentages, for example, 100 percent for preventive care or 80 percent for restorative care, are generally Usual, Customary and Reasonable (UCR) plans. The administrators of UCR plans set what the plan considers to be a “customary fee” for each dental procedure. If your dentist’s fee exceeds this customary fee, your benefit will be based on a percentage of the customary fee instead of your dentist’s fee.


Exceeding the plan’s customary fee, however, does not mean your dentist has overcharged for the procedure. These plans pay a set percentage of the dentist’s fee or the plan administrator’s “reasonable” or “customary” fee limit, whichever is less. These limits are the result of a contract between the plan purchaser and the third-party payer. Although these limits are called “customary,” they may or may not accurately reflect the fees that area dentists charge. There is wide fluctuation and lack of government regulation on how a plan determines the “customary” fee level.


Question: “Do you take insurance as payment in full?”


Answer: While many offices do take insurance as payment in full, in the State of California, this is illegal. The state has investigators who check out various offices, and many dentists lose their licenses for engaging in this practice. They can possibly even go to jail if they do this on a wholesale basis. And while you may find some who will do it, they may be risking their careers.


You may be able to find some unethical dentists who will do this. Many of them will over-bill, pad the bill, and add extra charges to that insurance claim at the same time, but you’re putting yourself and the dental office at risk. You would be complicit in insurance fraud, a willing participant in committing a crime. If you and the other dental office are willing to take that risk, you may be able to find an unethical dentist who is willing to cooperate with you in committing insurance fraud.


What dental insurance covers

Not all dental plans are created equal, but a standard employer-provided PPO should cover between 80 and 100 percent of the cost for treatments like regular checkups, cleanings, fluoride and sealants. More critical work such as root canals or fillings are covered at anywhere from 70 to 80 percent, while major work like crowns or dentures typically come in at 50 percent coverage.


You also need to bear in mind the cost you’ll pay for each service. Dental plans come with a deductible each time you make a claim, which can range from $50 to $100. It’s possible to lower the amount you pay per month by increasing the amount of your deductible and visiting the dentist only once per year, but you run the risk of a huge bill if you suddenly need treatment. In addition, most plans have a maximum payout each year, often between $1000 and $2000. This seems like a substantial amount until you consider the costs of treatment: A periodic oral examination costs less than $100 on average, but a crown can cost between $700 and $800, while fixing a molar costs at least $600. As a result, your plan can quickly cap out.


Most plans cover 100% of preventive care. Preventive care usually includes an annual or twice yearly office visit for an exam, cleaning, x-rays and sealants. (NOTE: Sealants may be limited to certain age groups.)


Basic procedures are office visits for dental problems, extractions, fillings, root canals, and treatment for gum disease. You pay for part of these procedures as a co-payment, a set dollar amount (DHMOs) or co-insurance, a percentage of the cost (DPPOs and Dental Indemnity/ or Traditional Insurance).  A typical co-insurance amount is 80% or 70%. A DHMO policy will have a set dollar co-payment close to these percentages…


Major procedures are crowns, bridges, inlays, and dentures. They are usually covered at the highest coinsurance, such as 50%. DHMOs cover major procedures at a higher dollar co-payment. Root canals are also sometimes covered in this category rather than as a Basic procedure. So check your policy. Some carriers now cover implants under this category.



About half of dental PPOs, the predominant dental product in the market, have maximum annual benefit above $1500—half are less than $1500.  Deductibles for these products are usually between $50 and $100.  Some carriers now offer policies that roll some portion of an unused annual maximum over until the next year.  Whatever the annual maximum, only 4-7% of Americans (NADP Premium and Benefit utilization Trends Report, 2014—reflects 2013 data) with dental benefits hit their annual maximum.  This is a factor that employers weigh against the premium cost for higher annual limits.   NOTE:  DHMOs rarely have an annual maximum while most dental indemnity product annual limits parallel DPPO limits.


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