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Most dental insurance coverage breaks down into four distinct classes, based on the necessity, severity, and complexity of the work needed.
Dental plans usually group services into classes. These classes help determine whether a service is considered preventive, basic, major, or orthodontic, and they also influence how much the insurance company may pay toward the procedure.
Class I: Preventive Care includes basic preventive dental care measures such as periodic exams, general cleanings, deep cleanings, X-rays, sealants, and fluoride treatments. This type of care is typically 100% covered by most insurance providers and usually includes up to two visits per year.
Class II: Basic Procedures commonly includes fillings, tooth extractions, root canals, anesthesia, and periodontics, also known as gum disease treatment. Coverage depends on the insurance carrier and how the service is categorized.
Class III: Major Procedures commonly includes crowns, bridges, dentures, extensive oral surgeries, and necessary implants. Some services may be classified differently depending on the plan or insurance provider.
This would include basic preventive dental care measures, such as periodic exams, general cleanings, deep cleanings, X-rays, sealants, sometimes dependent upon age, and fluoride treatments.
This type of care is typically 100% covered by most insurance providers, and usually includes up to two visits per year.
Common examples of Class II procedures would be fillings, tooth extractions, root canals, anesthesia, and periodontics, which is gum disease treatment.
However, about half of the Top 10 insurance companies consider root canals a Class III procedure, so if you are prone to certain dental issues, it is critical to make sure you know how that particular treatment is covered.
How much of the cost will be covered depends on the provider and how the procedure is categorized. Each insurance carrier will have its own rules with regard to how much they will cover and how much will be the responsibility of the patient.
This coverage is usually covered at a certain percentage of the cost of the procedure. Some policies have a deductible that needs to be met before the insurance company will start to pay its portion.
Common major procedures would be crowns, bridges, dentures, either partial or complete, extensive oral surgeries, and any necessary implants.
Again, some of these could be classified as Class II depending on the plan or insurance provider. Each insurance carrier will have its own rules regarding how much they will cover and how much will be the responsibility of the patient.
This coverage is usually covered at a certain percentage of the cost of the procedure. Some policies have a deductible that needs to be met before the insurance company will start to pay its portion.
Orthodontic care involves the use of devices, such as braces, to correct abnormalities of the teeth and jaw.
This type of coverage is highly variable by provider, and there is usually an age limit in place. Commonly, dependents age 19 and younger are eligible. Check with specific insurance companies for more information on orthodontia coverage.
Other critical factors to research are the benefit limits on the insurance. With both high and low-end dental plans, there is almost always an annual maximum payout per person, per benefit period, usually January through December.
This means that once the maximum amount has been reached, any additional dental care costs must be paid out of pocket by the patient until the beginning of the new policy year.
The annual maximum varies based on the provider and the plan you select. Many companies offer multiple plans, and the plans with higher premiums tend to have higher annual maximum payouts.
Dental insurance providers also usually have waiting periods in effect for coverage. Most of the Top 10 insurance companies have no waiting period for preventive Class I care.
A 12-month waiting period for coverage on Class III procedures is common, but many companies also have waiting periods before Class II coverage takes effect, usually ranging from three to six months.
However, a few companies have no waiting periods at all. It is essential to inquire about waiting periods before selecting a plan, so you do not find yourself in a situation where you need a procedure immediately and find out it is not covered for three months.
All benefit limits will be outlined in the service contract, so read it carefully before purchasing any insurance.
We at Healthcare American have a broad knowledge of how dental coverages work and can help you choose the right plan for you and your family’s individual needs.
Please give us a call, and let us help you choose the right plan for your dental needs.
Dental insurance commonly breaks coverage into four classes: preventive care, basic procedures, major procedures, and orthodontia. Each class may be covered differently depending on the insurance provider and plan.
Preventive care may include periodic exams, cleanings, X-rays, sealants, and fluoride treatments. Many insurance providers cover this class at 100%, usually up to two visits per year.
No. Some insurance companies classify root canals as basic procedures, while others classify them as major procedures. If you expect to need certain treatments, it is important to confirm how the plan categorizes them.
Major procedures may include crowns, bridges, partial or complete dentures, extensive oral surgeries, and necessary implants. Coverage depends on the insurance carrier and plan terms.
Some plans cover orthodontia, but coverage is highly variable and often includes age limits. Many plans limit orthodontic benefits to dependents age 19 and younger.
An annual maximum payout is the most the dental plan will pay per person during a benefit period, usually January through December. After that amount is reached, additional costs are paid out of pocket until the next policy year.
Many dental plans have waiting periods. Preventive care often has no waiting period, while basic procedures may have a three-to-six-month waiting period and major procedures may have a 12-month waiting period.
Plans can differ in how they classify procedures, what percentage they pay, deductible requirements, annual maximums, waiting periods, and orthodontia coverage. Comparing helps you choose coverage that better fits your needs.
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