How does dental insurance work?
Most dental plans work less like medical insurance and more like a yearly allowance toward your care. They pay generously for the visits that keep teeth healthy, pay part of the cost of repairs, and stop paying once they reach a limit for the year.
Many plans sort treatment into groups and pay a different share for each. Your plan, not the dental office, decides which group a treatment falls into, but the usual pattern looks like this:
- Preventive care, such as cleanings, exams and routine X-rays, which plans usually cover most generously.
- Basic treatment, such as fillings, which plans usually cover in part.
- Major treatment, such as crowns, bridges and dentures, where the plan's share is usually smaller.
Does dental insurance cover cleanings?
Usually, and generously. Most dental plans treat cleanings and exams as preventive care and cover them more fully than other treatment, often twice a year. On many plans the deductible does not apply to them either.
That makes a cleaning and exam every six months the simplest way to get value from a plan. It is also how a small problem gets found before it grows into the major treatment that plans pay least toward.
What are a deductible and an annual maximum?
The deductible is the amount you pay yourself before the plan starts paying. It usually starts over each plan year, and not every plan year begins in January.
The annual maximum is the most the plan will pay toward your care in one plan year. Once it has paid that much, it pays nothing more until the next plan year begins, and whatever you did not use usually does not carry over.
That is why larger treatment is sometimes worth planning across two plan years, so ask about timing when you get your estimate. We will also tell you plainly when a tooth should not wait, because a problem that grows can cost more than any benefit you save.
Waiting periods, frequency limits and other fine print
Most surprises come from rules in the fine print rather than from a plan refusing outright. The ones worth knowing:
- Waiting periods. Some plans will not pay toward certain treatment until you have been on the plan for a set time, often longer for major work than for basic. Preventive care is often covered from the start.
- Frequency limits. Plans limit how often they pay for some things, such as two cleanings a year or a full set of X-rays every few years. If your gums need periodontal maintenance every 3 to 4 months, the plan may still pay for only two visits a year.
- Replacement limits. Many plans will not pay to replace a crown, bridge or denture until it reaches a certain age.
What does in-network mean?
A dentist who participates with your plan, often called in network, has agreed to accept the fees the plan has set. Outside the network, depending on the plan, your insurer may pay less and leave you more of the bill.
Pearisburg Dental Center is a participating provider with Delta Dental, Cigna and United Concordia, and works with many other plans too. Plans and networks differ even within one insurance company, so the list on our insurance page is a starting point, and a call with your card in hand is the real answer.
Estimates before treatment, and the claim afterward
Before any treatment beyond a check-up, you get a written estimate showing what your plan is expected to pay and what it leaves you. For larger work, we can send the insurer a pre-treatment estimate first and wait for its answer, so you know what it will pay before you commit.
Even then, an estimate is not a promise from the insurer: if other treatment uses up part of your deductible or annual maximum in the meantime, what the plan pays can change.
After your visit, we file the claim for you. Your insurer usually sends you a statement, often called an explanation of benefits, showing what it paid. If it does not match your estimate, call us.
No dental plan, or only Medicare?
If you have no dental insurance at all, the Virginia Dental Club is a membership plan for people in exactly that position. It is not insurance: there is no deductible, no annual maximum and no waiting period.
Original Medicare generally does not cover routine dental care, though many Medicare Advantage plans include dental benefits. Medicare dental benefits explains how to tell which you have, and if a new plan means a new dentist, switching dentists covers the move.
Questions patients ask
Do you take my dental insurance?
We are a participating provider with Delta Dental, Cigna and United Concordia, and we work with many other plans too. Coverage differs even between plans from the same company, so call 540-921-3323 with your card and we will check what yours covers here before you book.
What is the difference between a deductible and an annual maximum?
The deductible is what you pay each plan year before the plan starts paying. The annual maximum is the most the plan will pay in a plan year. One marks where the plan's help starts, and the other where it stops.
Why did my plan pay less than I expected?
Usually because of a rule in the plan: the deductible, a frequency limit, a waiting period, or an annual maximum that was already partly used. The written estimate before treatment is how we try to catch those in advance.
What should I have ready when I call about my coverage?
The insurance company's name, the plan or group number, the member ID, and the policyholder's name and date of birth. With those, we can check what your plan covers here before you book.