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What Does My Dental Insurance Cover?

Navigating the ins and outs of your dental insurance benefits can be confusing, especially if you need treatment. Understanding what’s covered — and how much it is — takes a lot of people back to their high school math class homework. Fortunately, we’re able to walk our Raleigh dental patients through their plan to navigate their path toward better health.

If you have questions about which type of dental treatments are covered by your insurance plan, here are some important things you need to know:

Preventative Dental Care

Great news. Dental insurance is primarily prevention-based. That means they highly encourage frequent preventative care appointments like exams, cleanings, fluoride, and sealants to reduce your risk of tooth decay. And if you do have something pop up, there’s a good chance you can take steps to reverse the early symptoms before the condition evolves into a disease.

Most insurance plans cover 100% of preventative services. However, there will be a few restrictions as to when and how often those procedures are available. For example, you can usually expect a “free” (included) cleaning every six months or twice a year. One set of bitewing X-rays is usually covered once per year, to screen for decay before it evolves into aggressive abscesses. For children, fluoride is usually included at every dental checkup. And protective sealants are usually covered 100% on specific teeth like 6 and 12-year molars until your child has reached 14 years of age.

Taking advantage of your included preventative care benefits is the best way to maximize insurance coverage and reduce out of pocket costs.

Restorative Dentistry

When a tooth needs to be repaired with a filling, crown, or another type of dental therapy, your insurance plan will slightly reduce the percentage of what’s covered. For instance, the plan may cover 80% of a filling or 50% of a crown. It’s more affordable to utilize your coverage as early as possible when the procedure fee is lower, and the amount covered is higher. Plus, earlier treatments maximize the amount of healthy tooth structure you’re able to preserve! It’s a win-win.

Emergency Dental Treatments

Most dental emergency treatment in Raleigh falls under restorative or major categories. Common examples include fillings, emergency tooth removal (extractions), or initiating dental crown treatment.

Ultimately the initial coverage will be for your emergency exam and X-ray. By the time we work to get you comfortable, we can discuss what treatment solutions are available to choose from. Interim emergency treatments tend to be affordable, yet temporary, giving you time to plan the next steps related to your cost of care.

Cosmetic Dentistry and Smile Makeovers

Is cosmetic dental treatment, such as smile makeovers, covered by insurance? The short answer is “it depends.” The longer explanation is that if the procedures are cosmetic-type restorative treatments (like white fillings or porcelain crowns) then they may be. But elective services like teeth whitening or porcelain veneers usually aren’t.

Any time we’re trying to ensure coverage on a possibly necessary cosmetic procedure, we can submit supplemental X-rays and photographs, along with a letter from our Raleigh dentist, directly to the insurance carrier. This extra information helps the company decide whether or not the procedure fits within their required guidelines for coverage.

Watch Out for Insurance Expiration Dates

With a few exceptions, nearly all dental insurance plans reset at the end of the year. Whatever unused benefits you didn’t utilize will not roll over into the new year. Once they’re gone, they’re gone for good. The “use them or lose them” mentality means that it’s financially better to tap into your coverage before December 31st. End of the year appointments can be in quite high demand, as most people are trying to catch up on getting their oral conditions treated before time runs out.

But at the same time, benefit reset dates are also a good thing. If you’ve exhausted your coverage for this year, the new year brings access to a full benefits package all over again. That’s why some people will schedule the first phase of treatment in November or December, and the second phase in January or February.

The Plan Your Employer Picked Out

Most people carry dental insurance through their employer. When they do, the company head or HR department is the one responsible for purchasing the best plan for their employees’ needs. A specific company — such as Aetna, Cigna, BlueCross BlueShield — doesn’t necessarily offer better insurance than another if the plans are different. Lots of people ask our Raleigh dentist which insurance company is best. But the fact is that carriers provide a plethora of plan options, so it’s up to the entity or person purchasing it (in this case, your employer) to weigh their options. Even then, the total amount of coverage may add up to around the same dollar amount; it’s just that it’s distributed differently.

This leads us to another important topic…

Keep Your Annual Allowable in Mind

Yearly maximum “allowable” amounts are the total dollars covered under your insurance plan. For example, most dental companies provide an allowable that’s capped at or around $1,500. So, you can use all of your dental benefits up to $1,500 in coverage before it expires. Anything that’s leftover past that amount would be your responsibility to cover out of pocket.

What surprises most people is that annual allowables haven’t increased with the cost of inflation the same way medical insurance plans do. The maximum allowable on most of today’s plans is about the same that it was back in the 1970s and 1980s. Unfortunately, the cost of materials, labor, and other expenses hasn’t remained stagnant, so many people feel that annual allowables are disproportionate to their oral health needs. Thankfully if you utilize preventative services covered at 100%, you can still avoid reaching your annual allowable amounts each year.

Did You Meet Your Dental Deductible?

Like your medical insurance, dental plans also require a deductible payment. Deductibles are the certain dollar amount that the patient or family is responsible for before the benefits “kicking in”. Keep in mind that deductibles usually don’t impact preventative care services like checkups and cleanings. They’re more closely tied into necessary restorative treatments, like when you have gum disease or tooth decay.

Depending on your insurance company and the plan you carry, your deductible may be quite different than that of someone else’s. It’s applied to your treatment plan and then the benefits package instantly starts covering the cost of procedures after that set amount. Be sure to provide your insurance information to our Raleigh dental office. We’ll call to verify coverage and deductible amounts well before we ever schedule treatment.

Financing Treatment Not Covered by Insurance

If you’re at the point where you’ve exceeded your annual allowable amount, need treatment that’s not covered by your insurance plan, or you don’t have insurance at all, there are still affordable payment options available.

Financing is offered on all dental services, whether or not you have insurance. If you need to work out a payment plan for a portion of your care and cover the rest with your benefits package, that’s fine. Most of our financing plans are 0% or low interest, making them easier to pay off at a low monthly rate that fits your budget. Approval is instant, so it’s possible to start on treatment the same day if you’re ready.

Do I Need to See an In-Network Dentist?

Not necessarily. Most dentists can take all PPO insurance plans even if they aren’t an “in-network” contracted provider. That being said, you’ll always need to check with our Raleigh dentist first to see if we’re able to file claims on your behalf. Certain types of insurance plans are quite restrictive, limiting you to only one or two providers within driving distance.

Using dental insurance at an out-of-network provider doesn’t necessarily mean you’re going to pay a lot of extra money for your dental care. Although the procedures could cost slightly more than an in-network dentist, you’ll still be able to utilize some of your benefits and access affordable, quality dentistry.

Customized Treatment You Can Afford

At Raleigh Dental Arts, our treatment coordinators work closely with your insurance plan to help you maximize your coverage. As we formulate the specific procedures you require and calculate your insurance benefits, you’ll be able to see a detailed line-item estimate of your care plan. If you have different treatment options, we can compare them side by side to contrast the costs and what’s covered.

Delaying your dental care allows the active disease to expand deeper into teeth, gums, bone, and surrounding healthy teeth. Treating it earlier minimizes your out of pocket costs while preserving as much healthy tooth structure as possible. If you have any concerns related to what’s covered by your dental insurance, please don’t hesitate to let us know!

Looking for a Raleigh dentist that accepts your insurance? Call Raleigh Dental Arts today to schedule your next appointment.


Tarun Agarwal

Dr. Tarun Agarwal, DDS is considered one of the top dentists in the country. He is a recognized speaker, author, and dental leader. He has been featured on CBS, NBC, ABC, FOX, and News 14 Carolina. Dr. Agarwal has been awarded '40 under 40' Business Leaders by the Triangle Business Journal. He is regularly invited to teach other dentists around the world and recently built a training center within the practice dedicated to sharing his expertise. Most importantly he is a loving husband and dedicated father of three wonderful children. His biggest accolade was being voted 'Best Dad in the World' by 2 of his 3 kids.