Most dental insurance coverage breaks down into four distinct classes, based on the necessity, severity, and complexity of the work needed. Your portion of the cost depends on which class the procedure is categorized as by your insurance provider. Outlining dental insurance coverage can be confusing, because a dental procedure may be considered Class I under one provider’s policies, but be considered a Class II or III by another. Let us look at how these service classes typically break down.
Class I: Preventive Care
This would include basic preventive dental care measures, such as periodic exams, general cleanings, deep cleanings, X-rays, sealants (sometimes dependent upon age), and fluoride treatments. This type of care is typically 100% covered by most insurance providers, and usually includes up to two visits per year.
Class II: Basic Procedures
Common examples of Class II procedures would be fillings, tooth extractions, root canals, anesthesia, and periodontics (gum disease treatment). However, about half of the Top 10 insurance companies consider root canals a Class III procedure, so if you are prone to certain dental issues, it’s critical to make sure you know how that particular treatment is covered. How much of the cost will be covered also depends on the provider and how the procedure is categorized. Each insurance carrier will have their own rules with regards to how much they will cover, and how much will be the responsibility of the patient. This coverage usually is covered at a certain percentage of the cost of the procedure. Some policies have a deductible that needs to be met, before the insurance company will start to pay their portion.
Class III: Major Procedures
Common major procedures would be crowns, bridges, dentures (partial or complete), extensive oral surgeries, and any necessary implants. Again, some of these could be classified as Class II, depending on the plan or insurance provider. Again, each insurance carrier will have their own rules with regards to how much they will cover, and how much will be the responsibility of the patient. This coverage usually is covered at a certain percentage of the cost of the procedure. Some policies have a deductible that needs to be met, before the insurance company will start to pay their portion.
Class IV: Orthodontia
Orthodontic care involves the use of devices, such as braces, to correct abnormalities of the teeth and jaw. This type of coverage is highly variable by the provider, and there is usually an age limit in place (commonly, dependents age 19 and younger are eligible). Check with specific insurance companies for more information on orthodontia coverage.
Other critical factors to research are the benefit limits on the insurance. With both high and low-end dental plans, there is almost always an annual maximum payout per-person, per-benefit period (usually January through December). This means that once the maximum amount has been reached, any additional dental care costs must be paid out of pocket, by the patient, until the beginning of the new policy year. The annual maximum varies based on the provider and the plan you select. Many companies offer multiple plans, and the plans with higher premiums tend to have higher annual maximum payouts.
Dental insurance providers also usually have waiting periods in effect for coverage. Most of the Top 10 insurance companies have no waiting period for preventive, Class I care. A 12-month waiting period for coverage on Class III procedures is common, but many companies also have waiting periods before Class II coverage takes effect, usually ranging from three to six months.
However, a few companies have no waiting periods at all. It is essential to inquire about the waiting periods before selecting a plan, so you do not find yourself in a situation where you need a procedure immediately and find out it is not covered for three months. All benefit limits will be outlined in the service contract, so read it carefully before purchasing any insurance.
We at Healthcare American have a broad knowledge of how dental coverage’s work and can help you choose the right plan for you and your family’s individual needs. Please give us a call, and let us help you choose the right plan for your dental needs.