How does insurance provide coverage for my dental care?

If you recently started with different dental insurance for 2025 or perhaps have insurance for the first time, you may wonder “how dental insurance works.” With so many different terms and types of coverage, it can undoubtedly be confusing. We believe in transparency and proactive care at our office and find that keeping our patients informed about their dental treatment and how their insurance works can keep everyone on the same page about what is best for the patient.

As our office can only utilize “PPO” insurance plans, we will focus only on how PPO plans work. We are unable to utilize any HMO plans at our office. PPO plans typically operate with the patient’s coverage (otherwise known as “benefits”) as either In-Network or Out-of-Network depending on the office and dentist that you visit. Our office and Dr. Yu are in-network and have the most major PPO insurance. It is also important to note that many plans have the same benefits for both In and Out-network, allowing patients to use their plan at any dentist they choose.

The insurance plan’s benefits are defined by an annual maximum, deductible, coverage categories, and limitations. Standard terms should be available to all plan members when they sign up or through their employer’s HR department. We will cover each of these briefly to help inform our patients about how they can impact their dental coverage.

What is a dental plan's Annual Maximum?

The Annual Maximum specifies the most an insurance plan will help pay for dental treatment in a given “plan year.” Most “plan years” are from January 1st to December 31st. However, some do differ based on when the plan or employer started. Unlike many medical / health insurance companies, where there is an “Annual Out of Pocket Maximum,” this is not a limit to how much the patient pays. Rather, this is a monetary limit to how much the insurance will pay annually.

Once the year “resets,” a new Annual Maximum will be available. This is part of why dental offices tend to be busy toward the end of the year, as many patients are looking to utilize their Annual Maximum before they “lose” it and it resets in January.

What is a deductible?

An insurance plan’s deductible is the amount that a patient must pay before the insurance will help with the copay for a procedure. Typically, this does not apply to all procedures; expressly, the deductible is commonly waived for all preventative procedures like exams and cleanings. Most plans offer a $0 copay on cleanings and exams.

For procedures that do require a deductible, the patient owes the amount prior to any insurance copayment. If a deductible is $50, and a dental procedure is $90, the dental insurance will only consider $90 - $50 = $40.

Furthermore, some plans offer a limit on the deductible with family plans. This means a family will only pay a maximum deductible in a year. While this can be a cost-benefit in some circumstances, these are often set reasonably high – meaning three or more family members would need work done before a $50 deductible could be waived.

What are the different dental coverage categories?

PPO insurance plans have different coverage based on the category of dental procedures. The simple definition of categories is 1) Preventative and Diagnostic, 2) Basic Procedures, and 3) Major Procedures. Most plans will specify a percentage of coverage for these three categories, typically 100% for Preventative and Diagnostic, 80% for Basic Procedures, and 50% for Major Procedures.

However, depending on the specific insurance company, the specific dental category that falls under each of the three may have slightly different definitions or coverage. For example, some companies consider Non-surgical Periodontal procedures (such as deep cleanings) a “Basic” service and would cover 80%, meaning the patient only has a 20% copay. However, some companies consider that same procedure a “Major” procedure and only cover 50%, meaning the patient has a 50% copay.

When looking at your insurance policy, knowing what categories are covered and at what percentage is essential. For example, you may need wisdom teeth extractions and want to know what your insurance expects to cover for that procedure. Additionally, you may look for orthodontic treatment like Invisalign and want to see if they cover anything – as some plans may state that at 0% coverage.

What are common dental insurance limitations?

Unfortunately, there are many different limitations to insurance coverage, but we can cover some of the most common ones. Most limitations are frequency-based, while some are age-based. For example, a fluoride application is typically limited to pediatric patients at age 14. A typical frequency limitation would be a replacement dental crown once every 5 years or dental fillings on the same tooth only once a year. Finally, a common one is limiting the number of dental cleanings being covered to twice a year.

Putting it all together

For example, you may be anticipating visiting your Winter Park dentist. The first visit will likely include a dental checkup, x-rays, and a cleaning. These procedures would typically all be covered at 100% with no deductible because they are all “Preventative and diagnostic.” Before the visit, you may have felt some sensitivity or pain, and anticipate needing a dental filling or crown. If a dental filling is required, you can find on your insurance that they are covered at 80% after your $50 deductible. However, you must also prepare in case a dental crown is required. Because it would be considered a Major service, you see that your insurance would cover 50% of that after our $50 deductible. If you need more dental work, you should also pay close attention to your annual maximum, which accrues whenever your insurance pays part of your dental visit.

If you need a dental visit or want help checking on your dental insurance, please give our office a call or make an appointment online. We are happy to help!