Getting coverage on the health plan exchange – or buying direct

If you can't get dental benefits at work, don't worry. There are two other ways to get affordable dental insurance plans for individuals and families: you can purchase a dental plan on your state's exchange (also known as the health insurance marketplace) or get it directly from a dental insurance company.

Health exchange dental plans can be a good choice for individual and family coverage, but they typically come with a few limitations. For one, you can only get a dental plan from the exchange if you are also buying a health plan. In fact, some exchange health plans include dental for adults – but if your exchange health plan doesn't have it, you may be able to add a separate standalone dental plan. Typically, there are restrictions on when you can apply for coverage on the exchange. In most cases, you can only do so during open enrollment, which typically runs from the beginning of November until mid-December. However, if you've had a "qualifying event" – for example, because you recently lost employer-provided coverage – you should be able to apply for a dental plan outside the open enrollment period. Also, if you have a dentist you like and want to stay with, your exchange site may make it hard to see whether or not that dentist is in the plan's network. The best way to check? Get the exact name of the plan, then call to see if your dentist is in the plan's network.

You may decide to go the other route and purchase coverage directly from a dental insurance company. You'll find that many companies, including Guardian, let you compare and buy affordable dental insurance plans conveniently online. Their websites usually have a dentist lookup feature that let you see if dentists are in-network. And unlike an exchange plan, when you purchase directly from an insurance company, there are usually no restrictions about when you can apply or requirements to buy other kinds of coverage – such as a health plan.

The different types of dental plans and how they work

Whether you go through the exchange or buy directly from one of the top dental insurance companies, you'll typically find a choice of plan options. Insurance companies frequently use the terms "full coverage" and "basic coverage" to describe their offerings. While there's no strict industry definition as to what services need to be covered in either type of plan, generally speaking, a basic dental plan typically covers preventive care such as checkups, cleanings, X-rays, and a few simple treatments, like cavity fillings. Full coverage or comprehensive coverage plans cover more services. For example, they may cover a broader range of preventive care services such as fluoride treatments and sealants – and they may cover those treatments in full or with just a small copay. Also, a comprehensive-coverage plan will typically cover other types of services and care, including:

  • Basic restorative care - This includes fillings, extractions, and non-routine X-rays
  • Major restorative care - Bridges, crowns and dentures
  • Orthodontic treatment - Braces and other types of teeth aligners  

Exchange plans are categorized as being either "High" or "Low," but that has more to do with the costs involved than the level of coverage you get as a plan member. According to the website:

  • The “high” coverage level has higher premiums but lower copayments and deductibles, so you'll pay more every month, but less when you use dental services.
  • The “low” coverage level has lower premiums but higher copayments and deductibles, so you'll pay less every month, but more when you use dental services.

The reality is, you have to look at the details, compare benefits and have an understanding of the different plans and coverage options. To help you do that, here's a high-level overview of how dental insurance plans work. 

The two most common types of plans are Dental PPOs and Dental HMOs

Do you have a dentist you like and want to continue seeing? The answer can help you decide which type of plan may be right for you.

If you answered yes – you want access to a specific dentist – you should look into a DPPO plan. DPPOs have a network of member dentists, but insurance companies typically let you go out of network to see other dentists. If you go with an insurer like Guardian with a broad nationwide provider network, your current dentist may well be "in-network". So check the plan's dental network information before you buy. 

If you aren't partial to a particular dentist, consider a DHMO. In this type of plan, you can only see in-network dentists – and because the networks are limited, you probably won't get to see your current dentist. The trade-off is generally lower costs and a simpler fee structure. 

The preventive/basic/major coverage formula

You may see a plan described as having 100/75/50 coverage. Here's what that typically means: subject to any applicable waiting periods, preventive care – checkups and cleanings – is covered 100% (you usually don't even pay a deductible); basic care items – like fillings and extractions – are covered at 75%; and major procedures like crowns, bridges, and root canals are covered 50%. There are variations on this formula, and some treatments may be considered "basic" in one plan and "major" in another. Also, it's common for insurance plans to have a waiting period before they will cover major treatment for a member.

Network discounts

Most dental plans have a dentist network. When you see an in-network dentist you also pay less because the insurance company negotiates discounted fees on your behalf. For example, if your dentist typically charges $100 for a filling, when he or she is in-network, you may only be charged $60-$70 – even if you haven't met your deductible yet. 

Premiums, deductibles, coinsurance, and caps

Even if you go to an in-network dentist, the cost you pay for a given dental treatment may vary widely depending on the insurance company and specific plan you choose. When you're looking at a plan's details, the following common items should be clearly spelled out to help you estimate costs: 

  • Premium The amount you pay (typically each month) for your dental insurance policy.
  • Deductible The amount you have to pay before the plan starts to pay for treatments. DPPO plans tend to have deductibles, but many DHMO plans do not.
  • Coinsurance The percentage of costs you have to pay for a visit or treatment once you've met your deductible. With a DHMO, there isn't a deductible, and you will typically pay a flat fee(co-pay) depending on the services received.
  • Annual Maximum The total amount your plan will pay in a given year. You have to pay for any amount over the maximum – but remember: if you go in-network, you will still be able to take advantage of the plan's discounted fees. 

Common features to look for in a plan, and how much you can expect to pay

First of all, try to think about your dental care needs. 

If you have never had oral health problems, a basic plan may be a good choice. But if you're older, or you or your spouse have had issues – or you have kids – then you should look into getting a comprehensive plan.

Next, think about what dentist you want to see. 

When people find a dentist they like, they tend to stay loyal to him or her: Over 60% of working Americans have been going to the same dentist for at least three years, and 32% have been with the same dentist for ten years.2 If you have a dentist you want to stay with, look for a DPPO (or a similar type of plan called a DEPO); then check to see if he or she is part of the plan's dental network. Plans with a large dental network – like those from Guardian – will help increase the odds of your dentist being in-network. 

But what if cost matters more to you than loyalty to a specific dentist? A DHMO might be a better value for you. However, since their networks tend to be limited, you might have to go a little farther out of your way to get care.

Look at the features and design of the plan you're considering. 

Some of the terms may seem confusing at first, but the concepts are pretty straightforward. As we noted before, you should look at the premiums, deductible, coinsurance, and annual maximum to understand all the plan's costs. In addition, you should pay attention to such things as:

  • Services and treatments covered: You may not recognize the names of all the items covered—but the longer the list, the better.
  • Waiting periods: Major treatments, such as a root canal, usually have a waiting period (e.g., six months) before they are covered. So don't wait until your teeth hurt to get a plan!
  • Primary dentist requirement: This is typical of DHMOs, but some DPPOs also have this requirement. It means you have to go through your regular dentist to get a referral to see a specialist.

How much does dental coverage cost? 

Prices vary by carrier based on the age of each person insured and where you live, among other factors. According to Guardian Direct, a 40-year-old individual in New York can get a comprehensive plan with coverage for braces and major procedures for under $50/month. The same person could have access to a lower-tier plan with basic service levels for just over $20/month. But remember: if you need a lot of dental services, the total yearly cost (including coinsurance and deductibles) of a basic plan may end up being greater than the cost for a full-coverage plan.

Don't put it off – dental insurance plans can be important for individuals and families.

Good oral health is an essential part of your overall wellbeing, and more than 90% of all common diseases have oral symptoms1.  The importance goes beyond detection: Guardian studies2 – and other third-party research – show that good oral health can help adults avoid or better manage serious health-related issues such as diabetes and heart disease. If you or your spouse can't get dental benefits through work, take a minute to look into your state's health insurance exchange or consider buying directly from a dental carrier. Look for a company with a large dental network and a range of DPPO and DHMO plans, like Guardian. Since all major dental carriers will offer a few options, take the time to compare the plans offered – and remember that the plan with the lowest premium may not provide the best dental insurance value for you and your family's needs. 

Frequently asked questions about dental insurance plans and coverage options

What dental coverage is best for my needs?

Different insurance companies offer different dental plans, features, and networks, and there's no single "best" dental option for all people. The best dental insurance for you is the plan that lets you see a dentist you like, covers the dental care you and your family are likely to need, and works within your budget.

How much does comprehensive dental insurance cost?

Rates typically vary by age and state, but as an example, a 40-year-old individual in New York can get a comprehensive plan with coverage for braces and major procedures for under $50/month. The same person could have access to a lower-tier plan with basic service levels for just over $20/month. 

Can you just have dental insurance?

It depends where you buy your coverage. If you want access to individual and family dental insurance on your state's exchange site, the answer is no: you can't get dental insurance without also buying regular health insurance coverage. However, if you purchase directly from a dental insurance company like Guardian, the answer is yes: you can just buy dental insurance without getting other health insurance coverage.

Is individual dental insurance worth it?

It's good to smile - so it's also good to have dental insurance. People with dental coverage are more likely to get dental health services, get dental care for their children, and experience greater overall health. And since checkups and cleanings are covered with most plans, that eliminates the #1 reason for skipping dental visits – perceived cost

Do health benefit plans at work include dental?

Some employer-provided group health insurance plans include dental benefits with health coverage. It's a good way to promote employee health and can simplify coordination of treatment among health care providers. However, it's more common for employer-sponsored group benefit plans to separate the two types of coverage.

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1  Accessed October 2021

2 "Stay in Good Company" Guardian Dental Health eBook Based on research from The Guardian Workplace Benefits Study: Fifth Annual, 2017. 

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