Dental insurance explained: waiting periods and limits

Dental insurance helps pay for cleanings, fillings and bigger work like crowns, but it works differently from health insurance. Most plans pay a high share of preventive care, a smaller share of basic work and a smaller share still of major work, up to an annual maximum, and many make you wait before major work is covered. Adult dental is not one of the ACA's essential health benefits, and Original Medicare does not cover most routine dental care, so many adults buy a stand-alone plan. The right plan depends on whether you mainly want cleanings covered or you know bigger work is coming.

The four main types of dental coverage

Preventive, basic and major: the coverage pattern

Most dental insurance groups services into three classes. A common design pays a high percentage for preventive and diagnostic care, a lower percentage for basic procedures and a lower percentage again for major procedures; you will often see it written as 100/80/50. Every plan sets its own percentages, so read the schedule rather than assuming.

• Preventive and diagnostic: cleanings, exams and routine X-rays.
• Basic: fillings, simple extractions, and in some plans root canals and gum treatment.
• Major: crowns, bridges, dentures, implants in plans that cover them, and in some plans root canals.
• Orthodontics: usually a separate benefit, often for children only.

The fine print that matters most

• Annual maximum: the most the plan pays in a year. Once you reach it, you pay the rest. Compare this first if you expect major work.
• Waiting periods: many individual plans make you wait months before basic or major services are covered. Some plans waive waiting periods if you had prior dental coverage.
• Deductible: often small and often waived for preventive care.
• Missing tooth clause: some plans will not pay to replace a tooth lost before coverage started.
• Frequency limits: for example, two cleanings a year, or one set of bitewing X-rays.

Dental coverage and Medicare

Original Medicare does not cover most dental care, including cleanings, fillings, extractions and dentures, according to Medicare.gov. Some Medicare Advantage plans include dental benefits, which vary widely in what they cover and how much they pay. If you have Original Medicare with a Medicare Supplement, a stand-alone dental plan is the usual way to add dental coverage. Our Medicare Advantage versus Supplement guide explains how that choice affects extras like dental.

Dental coverage for children

Pediatric dental is one of the ACA's essential health benefits. On Connect for Health Colorado it may be built into a health plan or offered as a separate stand-alone dental plan, so check which one applies when you enroll your family.

How pricing works

Premiums depend on where you live, your age in some plans, how many people are covered, the plan type and how rich the benefits are: higher annual maximums, shorter waiting periods and broader networks cost more. I do not quote prices here because they change by ZIP code and plan; I compare current plans for your situation when you call.

Questions to answer before you choose

• Is my current dentist in the plan's network?
• Do I need work beyond cleanings in the next 12 months, and what is the waiting period for it?
• Is the annual maximum enough for the work I expect?
• Would a discount plan cost less for my situation than insurance?

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The bottom line

If you mostly want two cleanings a year, many plans will do. If you know a crown or dentures are coming, the waiting period and annual maximum decide which plan is worth it. Tell me what your dentist has recommended and I will compare plans with you. Send Lisa a message or call (303) 887-8584.