What does dental insurance cover in the USA?

According to the latest studies by the National Association of Dental Plans, nearly 80% of Americans have a dental benefit or coverage. How do they get it? Well, through private policies or employer insurance. Now, it is important that you know that, in general, large companies and corporations offer a dental plan, something difficult to find in SMBs and smaller employers.

Dental plans are also associated with salary. In fact, the same study found that employees with higher titles and salaries usually have a dental coverage plan, while employees with smaller salaries lack it. At this point you may be wondering if Medicare covers dental care. The answer, unfortunately, is that it does not cover them. However, most state Medicaid programs do offer dental coverage, but only for the youngest members of the household.

If you’re thinking of making the most of your children’s Medicaid dental benefits or just want to purchase a dental coverage plan, welcome! The first thing you should do is determine what dental insurance covers in the USA.

What does dental insurance cover in the USA?

What types of dental coverage are on the market?

In the insurance sector, there are two ways to get dental coverage: 1) as part of a health insurance that you already have active or 2) by purchasing a special policy separately. Let’s see what this is about:

  • Health plans with dental coverage. There are many private health policies (purchased by your employer or your family) that include dental coverage. To find out if yours does, check the terms and conditions of the policy very well or call your insurance broker directly. (Remember that, in this case, you will pay a single premium for both types of coverage: health and dental).
  • Standalone dental plans. Some insurers offer stand-alone dental plans that you can purchase separately when you purchase your insurance policy. In this case, you will have to pay two premiums: the health insurance premium and the dental coverage premium.

What suits me? Dental insurance or dental benefits

This depends on your needs and budget. Typically, dental insurance plans have their own coverage. In this case, the insurer makes a list of the allowed procedures (such as a tooth extraction, root canal or dental cleaning per year) and also sets the total amount of coverage.

However, health plans that include a dental coverage section only bear partial risk. What does this mean? That it might cover some emergency treatment, but everything else you’ll have to pay for out of pocket.

Note: As you can see, health policies with dental benefits can be useful if you do not have specialized dental insurance. However, it will not keep you protected from any risk.

How do dental insurance premiums and copays work in the USA?

Although the list of expenses will depend on the insurer, we could summarize the total cost of dental insurance in the United States as follows:

  • high end policy. This type of insurance offers high coverage for dental care, both in terms of treatment and amount. The problem? Your premium is much higher than other options on the market. However, there is a positive point in all this and that is that the copays and deductibles will be much lower.
  • Low-medium range policy. In this case, the coverage and the list of dental treatments will be smaller. This has an advantage and a disadvantage. The good part is that your premium will be greatly reduced and it will be easier to pay. The bad news is that, in addition to having more limited coverage, you will have to pay much higher deductibles and copays.

Tip: Before purchasing a health plan with dental benefits or stand-alone dental insurance, we recommend reviewing the fine print. See how much the insurer will charge for premiums, deductibles, and copays; and what other benefits it offers.

What should you consider before buying dental insurance?

First of all, check to see if your employer-provided health plan offers dental coverage. Why? Because it will be much easier -and cheaper- than buying an extra dental policy on your own.

If your employer doesn’t have a good health plan or you prefer to buy your own dental insurance, we advise you to speak with your main dentist. He can guide you to acquire a plan that suits your needs based on your medical history.

Before signing the insurance contract, there are some elements that you should analyze with a cool head:

  • Does the insurer offer special coverage for emergencies?
  • Do you have any pre-existing conditions that may limit your coverage?
  • How much can you pay out of pocket? Will your annual budget withstand the blow?
  • Do you need orthodontics? If so, make sure dental insurance covers all braces.
  • Can you easily cover the total costs of the annual plan, that is, premiums, copays and deductibles?
  • Have you analyzed if the maximum annual coverage suits you? Is there a plan that offers you a better deal?
  • Does your dentist or dental specialist belong to the network of clinics, professionals or offices included in the dental insurance you want?
  • In which states of the country does the insurer work? If you travel and need urgent dental care, will you be able to get it through the plan?

Answer all these questions honestly to find out Which of all the dental insurances in the USA suits your needs.

What types of dental insurance are there in the USA?

Dental insurance is similar to health insurance policies (with a few differences). In simple words, We could summarize the types of dental insurance in the United States in three classifications:

PPO (preferred providers)

Dental PPO insurance is similar to health PPOs. In this case, you will have a plan that will show you a fairly complete list with all the dentists and dental health specialists that are registered with the insurer.

As usual, you can make an appointment with any of them by paying a reduced copay or deductible. If you need to assist you outside the network of affiliated professionals, you can do so; but risking paying much higher rates.

Discounted dental care

More than dental insurance, it is a plan with benefits. In this case, you will get a discount on any of the dental treatments or consultations you need. Unfortunately, through the discount plans you will only be able to access a select group of dentists.

But, let’s look at the positive side! Unlike health insurance, with a discount plan or dental referral you will not have to pay anything for the consultation. And if you need a special treatment, you will enjoy a juicy price reduction.

DHMO (oral health maintenance)

You could say that the DHMO is the same as the HMO of health insurance. This type of dental plan will also give you access to a wide network of dentists and dental health professionals, but with a difference: the copay amount will be fixed or the service will be available at no charge.

Of course, DHMO dental insurance also comes with drawbacks. The main one would be you will not be able to see a dentist outside the network, unless you are willing to pay for the entire treatment yourself.

Differences in dental insurance for children and adults

According to the United States Health Care Law, dental insurance for children has some differences when compared to that of adults. The reason? In the USA, dental coverage is a mandatory benefit for the youngest members of the household.

What this means is that, if you have health insurance for a child age 18 or younger, dental coverage must be available, either as one of the many items included in the plan or as an accessory plan.

In contrast, dental coverage is not an essential health benefit for adults. While insurers are obliged to offer it to parents so that their children are covered, the same will not happen when they acquire a policy for themselves.

What does dental insurance cover in the USA?

Coverage of dental plans in the United States varies depending on the type of insurance you choose. However, we could summarize it as follows:

  • Oral surgery and dental extractions
  • Orthodontic treatments (dental alignment)
  • Fillings, crowns and root canals
  • Share of cost for preventive dental care
  • One or two preventive visits to the dentist (per year)
  • Periodontic treatments (against gingivitis and periodontitis)
  • Prosthodontic treatments (dental implants and dentures)

Now, there are some aspects that you should take into account. If you have an individual policy, periodontal and prosthodontic treatments may be available from the second year of coverage.

As for orthodontics, insurers will give you an extra annex. Why does this happen? Because dental alignment is usually expensive. That is why insurance companies prefer to charge a separate additional fee.

How does dental insurance coverage work?

Most dental plans in the United States follow the 100-80-50 rule:

  • Preventive care at 100% coverage
  • Basic procedures at 80% coverage
  • Procedures greater than 50% coverage

However, this is not a law written in stone. There are insurers that cover 80% in any case and, to reduce your risk, they raise copays depending on the treatment. Too there are insurance companies that prefer to leave certain treatments off the list of coverage.

Important note: All dental plans have an annual coverage limit. For example, most dental PPOs offer a maximum coverage of $1,500. If your treatment exceeds that amount, you will have to pay the difference on your own.

Does my dental insurance cover pre-existing conditions?

In general, insurers that offer dental insurance in the USA they do not cover the treatments that the insured needs for suffering from a certain pre-existing condition. In this case, you will have to bear the full cost of the treatment.

Tips to take advantage of your dental insurance

For optimal dental health, you should visit your dentist at least twice a year. Ideally, you should try to match these visits with those that are included in your policy for free. If you need other special procedures, it is important that you consult with your dentist and insurance broker.

Think that, Generally, insurers set certain time limits for medical treatments or tests that the insured needs.. For example, you might find that your policy covers dental X-rays — meaning you won’t have to pay for them — but only once every three years.

The same would happen with other treatments, such as the application of fluoride for children, fillings of the same tooth, etc. Our advice? Read your dental policy carefully to find out what procedures are covered and what restrictions apply before each treatment.

This will help you understand what coverage you have and how to make a plan of action in case of a dental emergency.

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