How Does Individual Dental Insurance Work?

how does dental insurance work


How does dental insurance work? By and large, dental insurance plans are pretty straightforward, and with a little information anyone can understand them. In fact, I’d bet my two front teeth I can explain how health insurance works in under five minutes. Shall we try?

Here’s everything you need to know about how dental insurance works.



What is Dental Insurance?

Simply put, individual dental insurance is a contract between you and your health benefits carrier – in our case, Delta Dental of Washington. When you enroll in an individual dental plan, you have entered into a contract. This means that you are responsible to pay your premiums and follow the rules of the plan and we’re responsible to pay your dentist for covered services at agreed upon reimbursement levels.

Dental plans vary, so the reimbursement level – or portion that the benefits carrier pays - depends on the plan you choose.

How Dental Insurance Coverage Works

If you get familiar with a few key terms, dental insurance coverage is also surprisingly transparent. Unlike medical insurance, dental insurance plans have a relatively small number of coverage categories. So, it’s easy to keep track of what dental services are covered and how much your dental plan pays for each service.

Preventive care (also called diagnostic services)
These services and treatments include: cleanings, oral exams, x-rays, fluoride and sealants. They can also include: periodontal (gum) maintenance and deep pocket cleanings.

Restorative and major services
These include fillings, crowns, root canals, extractions, oral surgery and specialty treatments for gum and teeth structures (periodontics), insides of teeth (endodontics), artificial removable teeth (prosthodontics), and braces (orthodontics).

These dental services are reimbursed at different rates, typically 50%, 70%, 80% or a flat fee. Your dental plan document should list each of these services individually, along with the percentage of coverage or the flat fee cost. You will be responsible for the remainder of the cost.

Buying Individual Dental Insurance

There are a couple of different ways buy a dental insurance plan. How this works depends on the type of coverage you need and how you purchase your insurance.

Health benefits exchange:
Many dental insurance carriers offer plans through a health benefits exchange. In Washington State, we have the Washington Health Benefit Exchange (WAHBE). These plans are designed to meet the needs of families with varying budgets.Currently, dental insurance plans can only be purchased through the exchange along with a medical insurance plan.

Standalone plans:
A good number of dental insurance carriers also offer standalone insurance plans. These are purchased directly through the insurance carrier. These are purchased directly through the insurance carrier. In this case, you can buy a dental insurance plan even if you have no health insurance.

Using Your Individual Dental Insurance Plan

When you are ready to use your dental insurance plan, find a dentist in your plan’s network. In our case, our dentists can join two networks. Dentists in the Delta Dental PPO Network often have agreed to accept lower fees than dentists in the Delta Dental Premier® Network. Dentists who choose to not join one of our networks are called Non-Participating Dentists.

You may choose any dentist to provide services under almost all of our individual plans;. However, your out-of-pocket costs may be substantially higher if you use a Non-Participating Dentist than with a Delta Dental PPO or Delta Dental Premier Dentist. You will be responsible for payment of any balance remaining after the DDWA benefit is paid.

Many dental insurance plans no longer issue physical cards. Not to worry. If a dentist is in your plan’s network, he or she has a “direct line” to the insurance company. The receptionist or billing specialist can look you up in our system to verify your coverage and benefits.

Dental Insurance Claims

In order for your dental insurance carrier to pay for your dentist bills, you or your dentist have to send in a claim.

Usually your dentist will submit claims for you.

We generally process all claims within 30 days, unless special circumstances require more time. Once we have processed your claim, we will send you and your dentist a notice to tell you what we paid - called an Explanation of Benefits (EOB). The EOB shows you what we have paid on your claim and how we applied your benefits and any copayments or deductibles.

Need Dental Insurance Right Now?

We offer 5 dental plans with different coverage and monthly premiums.

Important Dental Insurance Terminology

Hopefully you now have a clearer picture of how dental insurance works. As you shop for coverage, here are a few key terms to further explain dental insurance plans.

Premium: This is the amount you pay each month to be enrolled in a plan. For your plan to remain in effect, you must pay the premium on time.

Deductible: The amount of money that you must pay toward the cost of dental treatment before the benefits of the plan go into effect.

Coinsurance: The amount you pay (usually shown as a percentage) toward the cost of your dental treatment after the insurance company has paid their share.

Copay: A flat fee that you pay out-of-pocket for certain dental services. The copay is a predetermined amount and doesn’t change, regardless of how much your dentist charges the insurance company for services.

Annual / Plan-Year Maximum: The total your plan will pay each year for specified dental services.