Some Answers to Some Dental Insurance Questions

Things to know

Deductible

Similar to car insurance, this is the amount you pay before your benefit plan begins to pay the cost of your dental treatment. A deductible usually doesn’t apply to diagnostic and preventive treatment.

Dual coverage

You might have benefits from more than one dental plan, which is called dual coverage. In this situation, the total amount paid by both plans can’t exceed 100% of your dental expenses. Depending on the specifics of the plans, your coverage may not total 100%. 

Maximums

This is the most money a dental plan will pay for dental care within a benefit period. Once you reach the maximum amount, you’ll pay any costs for the remainder of the benefit period.

Generally, Delta Dental PPO and Delta Dental Premier plans have maximums and deductibles, but the DeltaCare USA plan does not.

Coinsurance

If you have a fee-for-service benefit plan, your plan pays a predetermined percentage of the treatment cost and you’re responsible for paying the balance. This part of your out-of-pocket costs is known as “coinsurance.” Delta Dental PPO and Delta Dental Premier plans have coinsurance.

Reimbursement levels

Fee-for-service dental plans offer different categories of coverage, each tied to a certain percentage. For example:

• Diagnostic and preventive procedures, such as cleanings and checkups, are typically covered at the highest percentage (for example, 80% to 100% of the plan’s contract allowance). This gives you a financial incentive to get regular checkups and cleanings to prevent the need for more extensive procedures.
• Basic procedures, such as fillings and gum treatment, are usually reimbursed at a slightly lower percentage (for example, 70% to 80%).
• Major procedures, such as crowns and root canals, are usually reimbursed at the lowest percentage (for example, 50%).

Procedures can fall under a different category depending on your plan. Please see your plan booklet or Policy for a complete description of benefits, limitations and exclusions.

Copayment

If you have a closed network, prepaid, fixed copayment plan, you pay a set dollar amount for covered services, instead of a percentage. (Some services may have no copayment.) When you enroll, you’ll receive a list of covered services and their copayment amounts. These types of plans usually have no annual deductibles or maximums.

Pre-treatment estimate

If your dental care is extensive and you want to plan ahead for the cost, you can ask your dentist to submit a pre-treatment estimate. This estimate includes an overview of services covered by your dental plan and how any applicable coinsurance/copayments, deductibles and dollar maximum limits might affect your share of the cost. While it’s not a guarantee of payment, a pre-treatment estimate can help you predict your out-of-pocket costs. estimates.

Limitations and exclusions

Dental plans are intended to cover part of your dental expenses, so you may not be covered for every dental need. A typical plan has limitations, such as the number of times you can receive a cleaning each year. In addition, some procedures may be not be covered under your plan, which is referred to as an “exclusion.” To find out how any limitations or exclusions would affect your share of the cost for a treatment, review your plan booklet or Policy or obtain a pre-treatment estimate.

In addition, a procedure covered under your plan might be limited or denied based on a clinical review by one of our licensed dental consultants. These decisions are based on the standard of care all dentists are required to follow. You may obtain a copy of these guidelines by sending a written request for the following benefit categories:

• Basic benefits
• Crowns, inlays, onlays and cast restoration benefits
• Prosthodontic benefits such as fixed or removable appliances