5 Reasons You May Owe Money Out of Pocket at the Dentist

Dental benefits are designed to save you money. If you understand your dental plan, you are better equipped to save money and maintain good oral health!

Delta Dental plans often cover 100 percent of routine preventive and diagnostic care. This includes procedures like cleanings, exams and x-rays because we believe in the power of preventive care. When you maintain your preventive care appointments, your dentist can help make sure you're less likely to need restorative dental care procedures down the line.

Let’s review when dentist visits may end up costing you money out of pocket and how that fits into the cost of dental benefits.

1. Your dental plan has a deductible

With dental coverage, a member may sometimes pay money “out of pocket.” That means that when they get dental care, they have to contribute a certain amount each year before their plan begins to pay for covered dental treatment costs.

You must pay for your dental care until your plan’s deductible is met, unless it’s something 100 percent covered by your plan. But, you only have to meet your deductible once in a plan year. 

Preventive care services like cleanings are covered at 100 percent right off the bat, even if your deductible hasn’t been met yet.

Sign into your member portal or check your member ID card to see what your plan’s deductible is. 

2. Your dental plan doesn’t cover 100% of the dental work you need

After your deductible is met, your insurer will pay for a percentage of treatment costs. You, the member, may also be required to pay the remaining balance after the insurer pays their percentage of the cost. This is known as “coinsurance.” Paying money out of pocket for coinsurance will not start until you’ve met the required deductible, so you won’t be paying both at the same time. 

If your dentist comes across signs of a cavity during an appointment, fillings, root canals and tooth extractions are often covered at 80 percent. That means Delta Dental will pay the majority of the cost, leaving you with 20 percent to pay. The 80/20 split between you and your dental benefits provider is your “coinsurance.”

 3. Your treatment requires a copay or copayment

When you choose your dental plan, you should note if there are copayments or copays required. These are fees required after dental services. All copays are a fixed dollar amount that won’t change depending on the cost of the dental work you’re getting. 

4. You hit your annual maximum and still have treatment scheduled in that plan year

Many dental plans have an annual maximum. This is the maximum dollar amount that a dental insurance provider will pay toward treatment during one plan year. For example, say your plan states that your annual maximum is $1,000 and, in one plan year, you had three restorative dental procedures that totaled $1,300. Because you exceeded your annual maximum by $300, you are responsible for paying that $300.

Once the plan year resets, your annual maximum does, too.

5. Your treatment isn’t covered by your plan

Dental coverage depends on your plan’s specific design, and not all plans cover all treatments!

If you want to have veneers put on your teeth or a special whitening treatment done, these would most likely be considered cosmetic services. Cosmetic dental procedures focus on improving the appearance of a person’s mouth rather than providing medically necessary care. Cosmetic services would not be covered by your dental benefits plan, so you’d have to pay the total cost.

Here are some ways you can save on the cost of dental benefits:

1. Visit in-network dentists.
2. Keep up with your preventive care appointments.
3. Keep an eye on your deductible and annual maximum as the year goes on. 

Since preventive care is almost always covered at 100 percent, make sure you’re scheduling your appointments as often as your plan allows to maximize your benefits.