The next level of benefits is called Basic care. Basic care includes treatments for many common dental issues and is usually covered with a relatively low cost share, such as 20%. These treatments include fillings, tooth extractions, and root canals. The insurance carrier would pay for 80% of the allowed amount, and the insured would pay the other 20%. Often, dental plans include a small deductible that must be paid first.
The highest and most costly level of benefits is called Major care. Major services are dental work that is considered more extensive, expensive, or complex. These services include dentures, bridges, crowns, and implants.
Major care is usually covered at a higher cost share – such as 50% – where the insurance carrier pays half of the allowed amount and the insured pays the other half. Major care is also subject to the plan deductible if it has not already been met during that year.
Finally, some but not all dental plans include coverage for orthodontic services. This would include braces or Invisalign. More commonly, if orthodontic care is included in the plan benefits, it is for children only, but some plans do cover orthodontics for adults as well.
Dental plans have annual maximums that differ from the maximums on medical plans. For a dental plan, the annual maximum is the most that the insurance carrier will pay out towards benefits in the calendar year. If you need services and the cost exceeds this amount, you would be responsible to cover these yourself.
This annual maximum resets each year, and some plans even include a rollover provision, whereby you can bank some of the annual maximum from a prior year if you have not used it. As with medical plans, it is always advised to use a dentist that is in your plan’s designated network in order to have the insurance carrier pay the maximum allowed and to keep your personal cost at the lowest level. Many dental plans do include reimbursement for out-of-network services, but individuals must keep in mind that an out-of-network dentist is not prohibited from balance billing above the amount the insurance deems reasonable.