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Understanding Dental Insurance Plans: Navigating Your Coverage

Dental benefit plans, often informally referred to as dental insurance, play a pivotal role in making dental care more accessible. However, it’s essential to recognize that dental benefit plans function differently than traditional health insurance. In this article, we’ll delve into the intricacies of dental benefit plans, the key terms you should be familiar with, and how to ensure that your treatment decisions for your child prioritizes their oral health over the insurance coverage constraints.

What Is a Dental Benefit Plan?

Dental benefit plans are specifically designed to assist in covering the costs associated with dental treatments. While they are often referred to as “insurance,” they operate as a distinct branch of healthcare. Dental benefit plans offer coverage for various procedures, but it’s crucial to understand that not all services will receive the same level of coverage. Some treatments are fully covered, while others are only partially covered, and some may not be covered at all. Familiarizing yourself with the details of your plan is essential. If you have any questions regarding your child’s dental insurance plan, contact our insurance specialists to be able to help navigate and answer any questions you might have.

How Dental Benefit Plans Work

Dental benefit plans are not all-encompassing; they cover specific dental costs and needs, and these terms can vary between plans. Many dental plans operate under contracts between employers and dental plan providers, but you can also purchase individual dental plans independently or through health insurance marketplaces.

Your Dental Coverage Is Not Determined by Your Dentist

It’s important to note that your pediatric dentist’s primary focus is your child’s dental health. However, not every procedure your dentist recommends will be fully covered by your dental benefit plan. The dental insurance bases coverage on how much they choose to pay out, a lot of times it is based on how much you or your employer pay into the plan.

Key Terms for Understanding Coverage

To grasp how dental benefit plans share treatment costs with you, you need to be familiar with some key terms:

Deductible: This is the initial amount you must pay before your plan starts covering any service. Deductibles are not usually required for diagnostic and preventive services, like exams, cleanings and some x rays.
Coinsurance: After meeting your deductible, you’re typically expected to pay a percentage of the allowed benefit amount for a covered service. For example, your plan may pay 80%, and you pay the remaining 20%.
Annual Maximum: This represents the highest dollar amount your dental plan will pay during a year. Any costs exceeding this amount become your responsibility. A dental maximum typically resets in January for calendar year plans. Click here to find out how to maximize your dental insurance.
Pre-Existing Conditions: Dental plans may not cover conditions you had before enrolling, even if treatment is necessary. You’ll be responsible for these costs.
Coordination of Benefits (COB): This applies when you have multiple dental plans, or dual insurance, ensuring that total benefits don’t exceed the charges. Each plan handles COB differently. For example, just because you may have two or more dental plans, there is no guarantee that all of the plan will pay for your child’s services. There are time when only the primary plan will pay (the insurance is the one who determines who is primary).
Plan Frequency Limitations: Plans may restrict the number of times they cover a specific treatment, even if your child requires it more often for their optimal oral health.
Not Dentally Necessary: Some plans only cover “medically or dentally necessary” procedures, and denials do not necessarily reflect the clinical judgment of your dentist.
Other Cost-Control Measures: Dental plans may employ various strategies to control costs, such as:
- procedure bundling: the insurance may combine two codes into one, which means they will only pay on one service
- downcoding: this is when the insurance will pay on a lesser service (less expensive for them, but not necessarily better quality)
- least expensive alternative treatment (LEAT).

How Do I Find Out What Is Covered?

Upon enrolling in a dental benefit plan, you should receive a benefit plan summary that details covered services, deductibles, coinsurance, annual maximums, reimbursement levels, limitations, and exceptions. If you have any questions you can always contact the Sorenson Pediatric Dentistry team to help.

Make Your Child's Dental Health the Top Priority

While it can be tempting to base your child’s dental care decisions on your plan’s coverage and what your insurance will pay, it’s vital to remember that your child’s health should always take precedence. Engage in open discussions with your child’s dentist to ensure that your chosen treatment plan aligns with their oral health needs, rather than solely focusing on what your dental benefit plan will pay for. Your child’s smile and overall well-being are worth prioritizing above all else.

Make your child’s dental health the top priority!

If you have any questions regarding your child’s dental insurance call our office and the team at Sorenson Pediatric Dentistry will help you to understand your dental insurance plan

Call us and schedule your child’s appointment today: (702)586-4347