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Dental benefits explained

Carrie Alles, Senior Product Manager • May 12, 2017
We know dental insurance terms can be tricky to understand. This guide will help you better understand how dental plans work so you can get the most from your coverage.

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The best way to take full advantage of your dental plan is to understand its features.

There are two ways to review your coverage:

  1. Read your benefit booklet for a complete, detailed description of your plan coverage.
  2. Create or sign in to your MySmile® account and select “Coverage overview.” It gives you a great summary of your plan’s coverage.


Knowing your plan’s coverage helps eliminate surprises at the dental office.

Key things to look for are your plan’s:

  • Dental network
  • Benefit period
  • Deductible
  • Maximum
  • Copayments and coinsurance
  • Classes of benefits
  • Reimbursement levels
  • Waiting period

To help you understand what you’re looking at, we’ve broken down these terms for you below.

Dental network


To get the most from your benefits, we encourage you to see a dentist who participates in your plan’s network. These are called “in-network” dentists. They provide services at discounted rates and file all claims paperwork for you. You get the best out-of-pocket savings when you see an in-network dentist.

If you choose a non-participating dentist, you’re responsible for making sure they complete your claim forms and send them to us.

We have four dental networks, designed for specific plans.

Here’s a breakdown:

Plan
Delta Dental PPO ℠
Delta Dental Premier®
DeltaCare®
SimpleChoice®
Dental network
Delta Dental PPO network
Delta Dental Premier network
DeltaCare network
Simple Access® network
Bonus tip:  Delta Dental Premier network dentists will provide services at discounted rates for PPO plan members.

Need a dentist? Use our Find a Dentist tool to search for one in your plan’s network.

Benefit period


A benefit period is simply the time frame in which you may use your plan to receive care. Your coverage begins on your plan’s effective date and ends on the last day of your benefit period. Most plans have a yearlong benefit period.

For example, let’s say your effective date is January 1, 2017. That’s the date you could begin using your coverage. Your benefit period is January 1 – December 31, 2017. This means your coverage is only good through December 31, 2017.

If you do not renew after your benefit period ends, you will no longer have coverage.

Deductibles


Most dental plans have a deductible. It’s kind of like the buy in for a poker game and works just like your car insurance deductible.

During your plan’s benefit period, you will have to pay a portion of your dental bill before your plan pays towards your bill. Many dental benefit plans waive deductibles for preventive and diagnostic services. Be sure to check your benefits to see if this applies to your coverage.

Maximums


There are two types of maximums you may see on your plan. They are annual maximum and lifetime maximum.

An annual maximum is the maximum dollar amount your plan will pay towards the cost of dental care within a benefit period. For many plans, preventive and diagnostic services are exempt from annual maximum accumulation. This means the plan pays these benefits in addition to the annual dollar maximum.

Many dental plans have an annual dollar maximum. Our DeltaCare, Clear Plan, and qualified dental plans do not have annual maximums. You can see if your plan has an annual maximum by reviewing your personal dashboard in MySmile

A lifetime maximum is the maximum dollar amount your plan will ever pay towards the cost of specified dental services. Common dental services with lifetime maximums include TMJ and orthodontia. 

If your dental care costs exceed your annual or lifetime maximum, you are responsible for paying your dentists all costs above it. Your plan will not pay. However, Delta Dental will process your claim to be certain you receive the dentist’s discounted fee for in-network care.

Copayments and coinsurance


Some dental insurance plans have a copayment policy. That means you and your plan split the cost of your dental care at a predetermined level or percentage. What you pay to your dentist is called the copayment.

Copayments are paid even after your deductible is reached.

Coinsurance is the amount you’re responsible for paying toward the cost of dental treatment after we’ve paid our portion. For example, let’s say your plan covers restorative treatments like fillings at 80%. That means we’ll pay your dentist 80% of the cost of your treatment. You’re responsible for paying your dentist the remaining 20%.

Reimbursement levels


Most dental plans group covered treatments into three classes. Each class includes specific types of treatment that are covered at a certain percentage, or reimbursement level. Each class also specifies limitations and exclusions.

Here is what services are typically included in each class:

Class I procedures are referred to as preventive and diagnostic. They’re covered at the highest percentage (usually 100%). This makes it easy and affordable for patients to get care that helps prevent most dental diseases.

Class II includes basic restorative procedures like fillings, extractions, and root canals. These treatments are usually reimbursed at a slightly lower percentage than Class I services. For example, they may be covered at 70% instead of 100%.

Class III is for major procedures such as crowns, dentures, and fixed partial dentures. These services are usually reimbursed at the lowest percentage (typically 50%). Class III may have a waiting period before services are covered.

Class IV is for orthodontic treatment (braces). These services are usually reimbursed at 50% and may have a waiting period.

Waiting period


Some dental plans have waiting periods for certain treatments. A waiting period is the length of time after your plan starts that you must wait before you can use your coverage for that treatment.

For example, let’s say your plan has a six month waiting period for crowns. If your coverage started on January 1, your coverage for crowns would begin six months later on July 1.
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