Dental Insurance 101

August 2, 2017 Uncategorized 0 Comments

Many of our patients choose to utilize dental insurance, which we understand can be very confusing! Although we are not contracted or “in-network” with any insurance companies, we can file for your “out-of-network” benefits as long as you have a dental PPO plan. A dental PPO plan allows you to either go in or out of network with regards to your dental provider. Most employer-based dental plans are PPO plans, but we do encourage you to check, as we are not able to file with any DMO or DHMO dental plans (meaning: if this is the type of plan you have, you would not receive any benefits at our office, and your visits would be out of pocket).  

Since we are not contracted with any insurance companies, there will often be a portion that the patient is financially responsible for. Some dental PPO plans pay very similarly as they would for in-network providers even when the patient chooses to go out-of-network – this is referred to as a “UCR,” “usual and customary” or “reasonable and customary” plan. This means that the plan pays the provider based off of what’s customary in the provider’s zip code with regards to fees. With this type of plan, we typically estimate that there will about a 10% patient responsibility (note: this is after coinsurances! – more info on those below) However, if it’s a plan that instead pays off of a “fee schedule” or off of “allowed amounts,” the patient is penalized a bit more for going out of network. In this case, we estimate that there would be closer to a 50% patient responsibility (also after coinsurances). If you would ever like to know what your insurance will pay out for a specific procedure or service before proceeding with it, we can always file a pre-determination for our patients. A pre-determination is essentially like filing a claim with your insurance company prior to a service, which will allow us to have a better idea of what your coverage will be.

Maximums and Deductibles  

With regards to your annual maximum and deductible(s), it is very different from medical insurance. With dental insurance, you have a yearly maximum available to you, and once you hit that maximum, you will not receive any more benefits until the next benefit period. Occasionally, plans might have rollover maximum, however most do not.

Also, dental deductibles differ from medical deductibles in that you typically have to meet your dental insurance deductible before any services beyond preventative services are covered. Typically, dental deductibles are small such as $25, $50, or $100. Occasionally, dental insurance deductibles do apply to preventative services, however they usually do not.


All dental plans have coinsurances that differ based on categories, some of the main categories being: preventive and diagnostic (e.g. exams, cleanings, x-rays), basic restorative (e.g. fillings), other basic services (e.g. root canals, periodontal procedures, extractions), major restorative (e.g. crowns, bridges, prosthodontics), orthodontics, and adjunctive services (e.g. nitrous oxide, night guards). After your yearly deductible is met, they will pay a certain percentage of certain services up to your benefit period maximum. For example, many plans pay 100% of preventative and diagnostic services, 80% of basic services and 50% of major services. Please note that these coinsurance percentages can vary based on the plan. Also, since our office is not contracted with any insurance companies, there may be a portion the patient is financially responsible for beyond their portion of the coinsurance.


Dental plans do assign frequencies for different types of services – basically, they allot the patient a specific amount of a specific service within a specific time frame. Beyond that, these services are no longer covered for the designated time frame. For preventative services (such as exams, routine cleanings and x-rays), plans typically allow two cleanings and exams within a benefit period of a year (or sometimes one per six months), one set of four bitewing x-rays, and so forth. For restorative procedures, such as fillings or crowns, the frequency is less often for each specific tooth. For example, a filling on a specific tooth is typically allowed one time within X amount of years.

Missing Tooth Clauses

A missing tooth clause often applies to a patient’s plan. This means that if a tooth was either lost or extracted prior to when the patient’s dental insurance was active, restorative/replacement procedures with regards to that tooth are not a covered benefit.

Waiting Periods

Waiting periods also often apply to a patient’s plan. This means that based on the category of services a plan designates has a waiting period (often major services, such as crowns), the plan will not cover it until the plan has been active for a designated amount of time (often 12 months). Some plans even have waiting periods for basic services, such as fillings.

We hope that this clears up a few things in regards to dental insurance! Please never hesitate to call us with any questions. Anyone at our front desk is glad to help you navigate your dental insurance!

-Austin City Dental

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