Understanding what your dental insurance covers can save you both time and money and help you make informed decisions about your oral health. While plans vary widely depending on the provider, coverage level, and whether you’re using individual or employer-sponsored insurance, most dental plans follow a fairly standard structure. Here’s a breakdown of what you can typically expect your dental insurance to cover.
Preventive Care – Usually 100 Percent Covered
Most dental insurance plans prioritize preventive care, which helps avoid more serious and costly problems down the road. This category typically includes:
- Routine exams (usually every 6 months, 2 per year).
- Professional cleanings (2 per year).
- X-rays (annually or as needed).
- Fluoride treatments (for children).
- Sealants (for cavity prevention in young patients).
Because preventive care is essential to maintaining oral health, insurance companies often cover 100 of these services with no out-of-pocket costs, provided you stay within your plan’s network.
Basic Restorative Care – Typically 70–80 Percent Covered
Basic dental procedures are usually partially covered by insurance, meaning you’ll pay a portion after your deductible is met. This category includes treatments like:
- Fillings for cavities.
- Simple tooth extractions.
- Root canals.
- Periodontal (gum) treatments.
Coverage for these procedures is usually around 70 to 80 percent, but it depends on your specific plan. Some plans may require a waiting period after joining before you’re eligible for these services.
Major Restorative Care – Typically 50 Percent Covered
Major dental work tends to involve more complex procedures and higher costs. These services are usually covered at a lower percentage, commonly around 50 percent. Examples include:
- Dental crowns.
- Bridges.
- Dentures.
- Surgical extractions.
- Some types of oral surgery.
Because these procedures are more expensive, most insurance plans will only cover a portion, and you’ll be responsible for the rest. Some plans also impose annual limits on the amount they will pay for dental services, often between $1,000 and $2,000 per year.
Orthodontic Treatment – Variable Coverage
Orthodontic care such as braces or Invisalign is not always covered, especially under basic dental plans. When it is, it’s usually limited to children under 18 and may have a separate lifetime maximum benefit. Some premium plans offer partial coverage for adult orthodontics as well.
Cosmetic Procedures – Usually Not Covered
Procedures that are considered elective or cosmetic, like teeth whitening, veneers, or cosmetic bonding, are typically not covered by dental insurance. These services are often paid out-of-pocket unless they are deemed medically necessary (for example, repairing a tooth after trauma).
How to Make the Most of Your Dental Insurance
- Get preventive care: Preventive care is not only covered, but it can save you the time, money, and headache of complications that arise later that aren’t detected in checkups.
- Know your plan: Understand what services are covered, your deductible, annual maximum, and any waiting periods.
- Stay in-network: Using providers within your insurance network can significantly reduce your out-of-pocket costs.
- Use benefits annually: Dental plans often have “use it or lose it” policies, so take advantage of your benefits before the year ends.
Dental insurance is a valuable tool to help manage the cost of maintaining a healthy smile. By understanding what’s covered and planning accordingly, you can take full advantage of your benefits while keeping your oral health on track.
About the Author
Dr. Nelson Y. Howard has practiced dentistry for more than 37 years. He is a graduate of the UCLA School of Dentistry and completed a one-year residency at the V.A. Medical Center in Los Angeles. Today, Dr. Howard maintains memberships in such prestigious organizations as the American Society for Dental Aesthetics and the West Coast Society for Cosmetic Dentistry, of which he is a founding member. Dr. Howard and our team of professionals will help you maximize your insurance benefits to achieve your dental goals. Schedule your appointment online today or call one of our two offices conveniently located in the San Diego and San Marcos areas.