Dental Insurance – Understanding Dental Insurance Exclusions

Dental insurance is a type of health coverage that reimburses part or all of the cost of certain procedures. It typically has deductibles, co-payments and policy maximums. It also lists fees that a plan administrator considers “customary” and reasonable.


Most dental plans follow a 100/80/50 payment structure, with most of the costs for preventive care and basic procedures covered and the remaining costs for major treatments. However, every policy differs.

Preventive care

Dental insurance is an option that helps manage costs associated with routine checkups and identifying issues early. Most dental plans include preventive care coverage such as bi-annual cleanings and oral screenings. Most also include basic care which includes tooth fillings, gum disease treatment and other procedures that fix damage caused by wear or injury. Dental insurance can be purchased as a stand-alone policy or in conjunction with a health plan.

Most dental plans come with a deductible which is the amount that the patient will pay each year before the insurance company starts paying. Some deductibles are low, while others can be quite high. Preventive services are typically covered without a deductible. However, some plans require that you see a dentist who is contracted with the insurer. These dentists have agreed to accept a negotiated fee for service which is lower than the usual, customary and reasonable (UCR) fee charged by non-contracted dentists.

Basic care

Many dental plans include coverage for basic procedures like check-ups (typically two per year), cleanings, fluoride treatments, and sealants. Most dental insurance plans also include coverage for x-rays and tooth extractions. In addition, most dental plans have an annual maximum which is the amount that the plan will pay for each procedure over a given time period, such as a year.

It is common for indemnity and PPO dental insurance plans to cover the costs of basic services at a rate of around 70 to 80% after the plan member has met the deductible. Many HMO dental plans require a modest copayment for these services.

It is important to note that most dental insurance plans exclude coverage for aesthetic or cosmetic services such as teeth whitening and braces (orthodontics). Some may also exclude coverage for athletic mouthguards, night guards, and use of nitrous oxide.

Major care

If you need a lot of work or you want coverage for expensive services like root canals and dentures, look for a plan with major care. These procedures are more invasive and complicated, and require a specialist, so they’re usually more expensive than basic or preventive services.

Most dental plans include a deductible, an annual coverage maximum, and copays or coinsurance for treatment. Some also have time limits for certain services, such as X-rays, which may be covered only once every 6 months or twice a year.

Most plans that allow you to choose your own provider have a preferred provider network, which offers lower costs for using in-network dentists. Others are fee-for-service, and limit you to specific dentists who will be reimbursed a set amount for each procedure. These plans generally have the highest premiums.


Dental insurance exclusions can seem like insurmountable obstacles to affordable dental care. However, with proper understanding and strategic planning, they can be turned into opportunities for better coverage and cost management. To start, it’s important to understand the different types of dental insurance exclusions. These include the’missing tooth clause,’ which excludes dental implants or dentures from coverage for teeth that were already missing before the policy took effect, as well as waiting periods and limiting procedures such as orthodontics and full mouth radiographs.

The most common dental insurance exclusions involve procedures that are considered cosmetic or not necessary for dental health, such as teeth whitening and veneers. In addition, many plans exclude or limit coverage for orthodontics, especially for adults. These limitations can cause people to delay or forgo needed treatment, which can lead to more serious (and expensive) dental problems down the road.


Many dental insurance plans have deductibles and copayments. Copayments are fixed amounts you pay for dental services, and they may count toward your deductible. Preventive care usually doesn’t have a copayment, and it is covered 100% by most dental insurance plans.

You can choose a plan that has a Preferred Provider Organization (PPO), an EPO, or a fee-for-service (traditional). The type of plan you select will affect how much you pay for dental care. For example, a PPO plan will usually cost less than an EPO plan because participating dentists agree to charge insurance companies a reduced rate for their services.

You should also consider annual maximums and whether or not you will be paying a premium. Higher-quality dental care usually costs more than basic procedures. Therefore, a plan with lower monthly premiums but higher coinsurance might save you more money in the long run.

Choosing a plan

Dental insurance plans can be confusing to people who are not familiar with the terms used by insurers. For example, a plan may limit the amount it will pay per year (known as an annual maximum) on certain services. These limits are set by contract and are often based on the insurer’s “customary” or “reasonable” fee for a specific area.

Choosing a plan is important because dental care can be expensive. Purchasing a dental insurance plan is an affordable way to help reduce the cost of care. However, it is important to consider a plan’s deductible, coinsurance structure, and out-of-pocket maximums when selecting a plan.

Some dental insurance plans use a preferred provider organization (PPO) network and offer a wider choice of dentists. Other plans, such as DHMO and discount dental plans, require that patients select a primary dentist from a list of participating providers. These plans typically have lower monthly premiums, but also lack the flexibility of a PPO plan.