Does Dental Insurance Cover Preventative Care?

Keeping your teeth healthy is an important part of keeping your overall health in check. That is why preventative dental care, including periodic cleaning and maintenance of your oral health, is critical not just for a healthy smile but also for a healthy body.

First of All, What is Preventative Dentistry?

We’ve already touched on one of the main features of preventative dentistry — routine regular check-ups performed in the office of your dentist. For most people, these regular visits to your dentist begin in early childhood and continue over the course of your life. Typically, routine dental visits are scheduled every six months or twice per calendar year.

What Kinds of Services are Performed at a Preventative Dental Visit?

• Lower the risk for developing serious dental issues such as gum disease, tooth decay, and others.
• Promote good oral hygiene.
• Identify dental problems early to minimize cost and treatment.
• Identify problems with your neck, mouth, and jaw that can be related to dentition.
• Reduce the incidence of dental problems typically associated with some chronic conditions such as eating disorders, osteoporosis, and diabetes.

Preventative services typically do not include fillings, root canals, and extractions. These are considered restorative services.

Will My Dental Plan Cover Preventative Dentistry?

If you have dental insurance, it is important to understand exactly what your insurance plan covers. About 77% of Americans have dental benefits, but this can differ from dental insurance. Dental insurance is meant to offset the risk that you will need a procedure — cavity filled, a root canal performed — and cover some or all the costs. Dental benefit plans cover some things entirely, some partially, and some not at all.

Depending on the type of plan you have, 100% of preventative dental services may be covered, or there may be limits on how much your plan will pay for each type of service. In general, dental plans fall into one of the following categories.

Direct Reimbursement

In a direct reimbursement program, you will receive reimbursement for a prearranged percentage of the cost of your dental care, regardless of what kind of treatment you receive.

UCR Programs

Usual, customary, and reasonable (UCR) programs typically set a reasonable or customary fee for dental visits, and they will pay up to this amount for treatment of any kind — or your dentist’s actual fee — whichever is less.

Schedule of Allowance Plans

These dental programs offer specific covered services for which they will pay a predetermined dollar amount, regardless of the fee charged by the dentist. Whatever part of the fee is leftover after they have paid their portion, the patient must pay.

Capitation Programs

These programs typically pay a pool of dentists that they contract a fixed amount for each beneficiary and/or their family members. These dentists will then provide specific treatment types for no charge to the patient or a small co-payment for certain treatments. If you participate in a capitation program, you will have to see one of the dentists outlined in the plan’s accepted pool of professionals rather than the dentist of your choice.

In general, most dental insurance or benefits programs will cover at least a portion of the costs of preventative dental care, typically for two visits per year, crowns, root canals, fillings, and even oral surgery. Some also even cover orthodontics or prosthodontics. Typically, dental programs follow a coverage structure of 100/80/50, covering preventative care at 100%, simple procedures at 80%, and major procedures at 50%.

Even so, you must review all of your dental plan information carefully to determine coverage details and ensure that you understand any out-of-pocket expenses you may incur from a scheduled preventative dental care visit.

Ensuring Your Preventative Visits are Covered by Your Dental Plan

As we mentioned, before scheduling a visit for routine dental treatment, make sure you understand the extent of your dental plan’s coverage and its limitations. Many plans have caps on what they will pay during a fiscal year, and you will be responsible for any expenses beyond that amount. That means if you need fillings, root canals, or other treatment beyond your preventative visit, your second preventative visit may not be covered if your plan’s cap has been exceeded.

Timing may be vital as well. Some plans will pay for two preventative dental care visits per calendar year, while others call for two within a 12-month period or even once every six months. There may be time constraints on other services such as x-rays, fillings on the same tooth, or fluoride treatments. If you are uncertain about your coverage, benefits, or timing of visits, make sure you contact your insurance company ahead of time.

For major procedures, your dental care provider can submit an estimate to your dental insurance or benefits provider to help determine what, if any, your final costs will be after deductibles, co-pays, and policy caps are considered.

At the Care Dental Center in Carson, we work hard to ensure that our patients have access to leading-edge preventative dental care. If you want to schedule a visit or have questions regarding the cost of preventative dental care, please contact us at (310) 626-0004, and we can help you get started!