By Dr. David Bryant, DDS – Denver, Colorado
It’s that time of year again. Your HR person sends an email with a printed brochure full of numbers and tells you it’s time to sign up for next year’s dental plan. But here’s what your employer probably doesn’t realize when they picked this plan: what you’re buying isn’t really insurance. It’s more like a Costco membership for your teeth, except Costco actually honors their membership benefits.
After 20+ years in Denver helping patients navigate this maze, I’ve come across so many of the clever ways these companies delay or avoid paying out benefits. Let me break down what you’re actually getting when you sign up for “dental insurance” and why our office spends an average of 20 minutes trying to get the details that these companies gatekeep and don’t publish on their online portals.
What Is Dental Insurance Really?
It isn’t actually insurance. Your benefit plan is more like a discount membership with a spending cap.
True insurance protects you when something catastrophic happens. What you get with dental “insurance” is more like buying a Costco membership. I like Costco; I love those blueberry muffins. At least their catch is simple, I just have to buy 2 six-packs of muffins to get the bulk discount. But imagine if every time you tried to buy them, they said “Sorry, you haven’t been a member long enough for the bakery section.” That’s dental benefits in a nutshell.
In my practice, I’ve watched these companies evolve from simple reimbursement plans into something that would make Syndrome from The Incredibles proud. “Think of the shareholders, Bob!” seems to be their guiding principle when designing benefit structures.
Does Dental Insurance Cover Everything?
No. Most dental benefit plans follow a “100-80-50” structure, and cosmetic work is almost never covered.
Here’s the typical breakdown:
- 100% coverage for preventive care (cleanings, exams, X-rays)
- 80% coverage for basic services (fillings, simple extractions)
- 50% coverage for major services (crowns, bridges, dentures)
- 0% coverage for cosmetic work (whitening, veneers)
Here’s the kicker even these percentages come with catches. In our office, we’ve seen patients shocked to learn their “80% coverage” for fillings doesn’t apply because they haven’t met some obscure waiting period they never knew existed.
Does Dental Insurance Cover Crowns?
Most dental benefit plans cover crowns at 50%, but only if they deem it “medically necessary” by their standards, not your dentist’s.
This is where things get frustrating. I’ve been placing crowns for decades, and I know when a tooth needs one. But dental benefit companies have their own ideas about necessity that often conflict with good dentistry. We spend considerable time sending X-rays, photos, and detailed clinical notes explaining why you need a crown, not because I enjoy paperwork, but because these companies will deny claims first and ask questions later.
Does Dental Insurance Cover Root Canals?
Yes, most dental benefit plans cover root canals at 50-80%, but remember you’ll likely need a crown afterward, which has separate coverage.
Root canals are usually covered because even dental benefit companies understand that saving a tooth is cheaper than replacing it. But here’s what they don’t tell you upfront after a root canal, that tooth typically needs a crown for protection. That’s a separate procedure with separate coverage, turning your “covered” root canal into a much larger out-of-pocket expense.
Does Dental Insurance Cover Implants?
Coverage is expanding, but it’s usually partial. Some dental benefit plans cover the crown but not the implant surgery itself.
This is actually good news compared to five years ago when implants were almost never covered. I’m seeing more plans that will pay for the crown portion of an implant, but they still balk at covering the actual implant placement surgery. It’s like covering the tire but not the wheel technically helpful, but not the complete picture.
Does Dental Insurance Cover Braces or Invisalign?
Some dental benefit plans include orthodontic benefits, but watch out for age limits. Many cut off at 18 or 19.
This is one of my “favorite” (and yes, I’m doing quotation fingers) dental benefit gotchas. Your HR department tells you about the great orthodontic coverage, but buried in the fine print is an age limit. I’ve had 25-year-olds excited about finally getting their teeth straightened, only to discover they’re “too old” for their benefits.
Does Dental Insurance Cover Wisdom Teeth Removal?
Yes, most extractions including wisdom teeth are covered. We’ll just need to document and justify the why.
Where it gets tricky is what do we do AFTER the extraction. Will they help pay toward replacing that tooth? This is something we will help you navigate at our office. We want to know options before we remove a tooth.
Does Dental Insurance Cover Whitening or Cosmetic Dentistry?
Nope. Dental benefit companies draw a hard line at anything they consider cosmetic.
This is where dental benefit companies are crystal clear if it’s about making you look better rather than preventing or treating disease, you’re paying out of pocket. Whitening, veneers, cosmetic bonding all considered elective. They’re in the business of basic dental health, not smile makeovers.
When we can find a clinical justification for a service, we can always appeal. Form follows function as my professor used to say. But there are definitely procedures that are purely cosmetic.
What’s the Difference Between In-Network and Out-of-Network?
In-network dentists accept heavily discounted fees from benefit companies. Out-of-network dentists maintain standard pricing.
An “in-network” dentist has accepted a large discount on their fees in exchange for the insurance referring patients. The benefit company gets to tell their members they have “great coverage” because they negotiated these discounts on your behalf.
Why would some dentists choose to stay out-of-network? Because some benefit company reimbursements are so low, and their billing requirements so burdensome, that it’s not economically viable to participate.
What Are Dental Insurance Waiting Periods?
Many dental benefit plans make you wait 3-12 months before you can use benefits for major services.
You’re paying premiums immediately, but you can’t access benefits for crowns, implants, or other major work until you’ve paid in for months.
What Is an Annual Maximum?
It’s the yearly spending cap typically $1,000-$2,000. After that, you pay 100% out of pocket.
Here’s where dental “insurance” shows its true colors. In health insurance, the annual maximum is often the most YOU’LL pay, with insurance covering everything beyond that. In dental benefits, the annual maximum is the most THEY’LL pay. Big difference.
Once you hit that cap which isn’t hard with major dental work every dollar becomes your responsibility. It’s like having a gift card that runs out, not true insurance protection.
How Much Does Dental Insurance Cost Per Month?
Typically $20-$50 per month from your paycheck, but your employer may be contributing additional amounts.
The monthly premium is just what comes out of your paycheck. Your employer often pays additional amounts to the dental benefit company that you never see.
What Are Those Sneaky Dental Benefit “Gotchas”?
Dental benefit companies use multiple tactics to limit payouts: missing tooth clauses, replacement clauses, age limits, and frequency limitations.
In 20+ years of practice, I’ve seen these tactics multiply:
- Missing Tooth Clause: Won’t replace a tooth lost before your coverage started
- Replacement Clause: Won’t cover replacing crowns/bridges for 5-7 years
- Age Limits: Cut off orthodontic coverage at arbitrary ages
- Frequency Limitations: Restrict how often you can get cleanings or other services
What About Dual Coverage?
Having two dental benefit plans (yours and your spouse’s) can reduce your out-of-pocket costs.
When you’re covered under two dental plans, they coordinate benefits so you typically pay less out of pocket. One plan pays primary, the other pays secondary, and between them, you often get better coverage than either plan alone.
Why Our Office Goes the Extra Mile
We spend 15-20 minutes per patient calling dental benefit companies to verify benefits and avoid surprise denials. We’re insurance-blind when it comes to clinical care and treat all patients the same.
Here’s everything we do to help you figure out the benefit maze:
Before Treatment:
- We help patients understand their benefits in plain English
- We spend additional time getting the full breakdown of coverage and all the gotchas
- We call benefit companies directly to verify what’s actually covered (not just what their website says)
- We get pre-authorizations for major work to avoid surprises
During Treatment:
- We submit all claims for you using Assignment of Benefits (AOB)
- We handle all the paperwork and follow up on processing delays
- We only ask you to pay your estimated portion upfront
After Treatment:
- We spend considerable time on the appeals process when benefit companies send out their default denials
- We gather supporting documentation, X-rays, and clinical notes to fight denials
- We follow up on unpaid claims until they’re resolved
Most dental offices will submit claims for you, but we go much further. We work hard for patients to use every benefit they’ve paid for. Why? Because we’ve seen too many patients get blindsided by denials and surprise bills when offices don’t do this legwork.
We give you advice based on your clinical needs, not based on what benefits you may or may not have. The appeal process can take 30-60 days, causing delays. During my years in Denver, I’ve noticed companies seem to deny first and ask questions later, knowing many providers won’t fight back on smaller claims.
What About UCR Fees?
UCR stands for “Usual, Customary, and Reasonable” fees, which is the full retail price for dental services in your area.
Think of it like shopping: out-of-network means you pay full retail price. In-network is like having a Costco membership that gets you discounted prices. But just like at Costco, your membership doesn’t make everything free. You still pay your portion, just at the discounted rate.
Understanding Frequency Limitations
Benefit companies love to limit how often they’ll pay for services, even when you clinically need them more frequently.
Common examples include cleanings limited to twice per year (some patients with gum disease need them every three months), X-rays limited to once per year, and fluoride treatments often limited by age. These restrictions are based on actuarial tables, not your individual dental health needs.
Our Alternative: In-House Membership Plans
For patients who want predictable dental care without benefit plan hassles, our membership plan offers 20% discounts plus included preventive care.
Our membership plan costs about the same as typical dental benefit premiums but includes:
- Two cleanings per year
- All necessary X-rays and exams
- Fluoride treatments
- Emergency visits
- 20% discount on all other services
No waiting periods, no age limits, no annual maximums, no missing tooth clauses. Just straightforward dental care with predictable pricing.
The Bottom Line
Dental “insurance” isn’t insurance, it’s a benefits plan with a spending cap and lots of fine print designed to limit payouts. Understanding what you’re actually buying helps you make better decisions about your dental care.
Don’t let your benefit plan dictate your dental health decisions. We’ve seen too many patients delay necessary treatment because they’re waiting for benefits to kick in or avoid recommended care because it’s not “covered.” Good dentistry focuses on preventing problems before they become expensive emergencies.
Whether you’re navigating dental benefit plans or considering our membership plan, our Denver practice is here to help you understand your options and get the dental care you need without surprise bills or bureaucratic runaround.
Ready to understand your dental benefits or learn about our membership plan? Schedule a consultation and we’ll explain your options clearly, no benefit company jargon, no fine print surprises.
Dr. David Bryant practices general dentistry in Denver, Colorado, with over 20 years of experience helping patients navigate dental care and insurance complexities. When he’s not decoding benefit plans for patients, he’s probably explaining why dental “insurance” isn’t really insurance to anyone who will listen.