How dental insurance plans work

Like regular health insurance, you pay a monthly premium for dental coverage, and the insurance company helps pay for your care. However, most dental care is preventive: checkups, cleanings, and simple procedures like X-rays and fillings that catch little problems before they become bigger problems. So dental insurance works differently, focusing on preventive and basic procedures – and some plans only offer those benefits. But you can also find more comprehensive "full coverage" dental plans where the insurance company typically pays for much more, including:

  • A broader range of preventive care services. For example, fluoride treatments and sealants
  • Basic care. This includes fillings, extractions, and non-routine X-rays
  • Major care. Bridges, crowns, and dentures
  • Orthodontic treatment. Braces and other types of teeth aligners  

Basic or comprehensive, many dental insurance plans cover standard preventive-care dentist visits 100%. You can find out more about what you'll pay for different services by looking at the preventive/basic/major coverage formula. Many dental insurance companies use a coverage formula to help people compare. For example, with a 100/75/50 policy: 

  • Preventive care – checkups and cleanings — is covered at 100%
  • Basic procedures – like fillings and extractions – are covered at 75%, and you just pay a 25% "coinsurance" charge
  • Major procedures – for example, crowns, bridges, and root canals – are covered at 50%

It's important to note that two policies with the same formula don't always offer the same coverage: some procedures may be considered "basic" in one policy and "major" in another. To find out what's what, you have to look at each plan's Plan Summary.

Most plans have a network of dentists

Some plans have a relatively broad network of dentists. Others – even from the same dental insurance company – may have a more narrow network (See Dental PPOs and HMOs below). Many plans even provide some coverage if you see an out-of-network dentist.

Deductibles, maximums, and waiting periods

Like health plans, dental plans typically have a deductible – an amount that must be paid out of pocket each year before benefits are paid. They also typically have an annual maximum that they will pay, and any dental expenses over the maximum are your responsibility. Finally, most plans also have a waiting period before they cover costly procedures such as crowns.

How dental insurance can help lower the cost of a dental crown

What exactly is a dental crown? It’s a cap a dentist puts over a tooth to restore its shape and function. It's usually needed after a root canal or if the tooth has been broken or weakened by a large cavity. No matter the reason, plans usually consider it to be a major procedure. It can cost between $500 and $3,000.

Here's what you could pay with a 100/75/50 plan. We'll assume you're past the waiting period, and your dentist's customary fee for the treatment is $2,000. With a 35% in-network discount, the dentist fee goes down to $1,300. After you pay your $50 deductible, the insurance company pays half of the remaining $1,250 charge ($625), and you pay the other half. So, your total out-of-pocket cost is $675 ($50 deductible plus $625 coinsurance). You save $1,325.

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

Should you choose a Dental Preferred Provider Organization (DPPO) or a Dental Health Maintenance Organization (DHMO)? The best way to answer is by asking yourself: Do you have a dentist you like and want to continue seeing? 

When people find a dentist they like, they tend to stay loyal to him or her: 32% have been with the same dentist for ten years3. So if you already have a dentist you like, you should look into Dental PPO plans. If you go with an insurer with a broad nationwide network, your current dentist may well be in the plan. For example, Guardian has over 120,000 dentists at more than 420,000 locations – and you can easily check to see if your dentist is in the plan you choose. 

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 their networks are limited, you probably won't get to see your current dentist. The trade-off is generally lower costs and a more straightforward fee structure: you'll typically have co-pays for covered treatments. 

And if you really don't like the idea of having a network? There's also a third type of dental coverage, called an "indemnity" plan, which lets you go to any dentist and reimburses a portion of your dental care expenditures. However, those plans are somewhat harder to find.

How dental care helps keep you healthier

Good oral health isn't a "nice to have" – it's an essential part of your overall wellbeing.1 More than 90% of all common diseases have oral symptoms.2  And the importance of oral health goes beyond detection: Guardian studies3 – and other third-party research – show that good oral health can help adults avoid or better manage serious health-related issues:

  • Diabetes Periodontal infections contribute to problems with glycemic control, which compromises the health of diabetic patients.
  • Heart disease The inflammation associated with periodontal disease has a high potential to contribute to coronary artery disease. Good oral health can lower that risk.
  • Pregnancy Studies have indicated that mothers with high levels of certain oral bacteria were found to have children with similarly high levels of bacteria, along with a higher risk of tooth decay.

Despite the importance of oral health, too many Americans avoid going to the dentist. Like other kinds of health care, dental procedures can be expensive – and that cost deters many from getting the care they need. Research conducted by the NADP shows that Americans with dental benefits are more likely to go to the dentist, take their children to the dentist, receive preventive care, and experience greater overall health. Guardian researchreinforces this finding as well:

  • Perceived cost is the #1 reason for skipping dental visits
  • More than 70% of working adults with dental insurance visit the dentist at least once a year – that drops to 40% when there is no insurance 

When people have dental insurance – either through the workplace or purchased individually – preventive care is typically covered at 100%. So there's no reason to let cost get in the way of a checkup – in fact, paying for insurance encourages many people to see a dentist to "get their money's worth." Checkups, cleanings, and X-rays can prevent many issues and catch others early on when they are far more manageable and less costly to treat. That can have a significant impact on your overall health and wellbeing – even more than you may realize.

How to find the best dental plan for your needs

You've taken an essential first step by finding out how dental insurance works and getting a better understanding of what's covered. You're ready to start looking for a specific plan. Here are some common-sense suggestions: 

1. Start by thinking about where to get your plan

if you can get dental insurance through your employer, you should begin there: companies get lower group rates because they buy benefits for many employees at once. Group plans often feature higher service and dental coverage levels. The company may also pay a portion of the costs, making it an even better value for employees. Don't have an employer? You may also be able to get group insurance coverage through a professional association or other membership group. 

If you need to get a dental insurance policy as an individual, that's okay too. It's still affordable – and many companies, such as Guardian, let you compare and buy coverage conveniently online. Dental plans are also available on each state's health care exchange – but to get a dental plan, you typically must first purchase regular health insurance on the exchange. 

2. Think about your budget

Many large providers (including Guardian) have different tiers of Dental PPO plans. Some also offer a Dental HMO plan. If you need to keep monthly costs down, consider a DHMO or an entry-tier DPPO plan that lets you use any dentist in network and get coverage for cleanings and basic procedures. 

3. Consider your dental care needs

If you've never had oral health problems, a basic, entry-tier plan may be a good choice. But if you or your spouse have had issues – or you have kids – then you should look into getting a mid or top-tier plan with more benefits and coverage for things like braces. The higher monthly premium amount may more than offset savings on major procedures. 

4. Decide whether it's important to see your current dentist

If you have a dentist you want to stay with, look to see if they are in-network. Guardian has an online provider search tool that makes it easy. Remember, since DPPO networks are larger than DHMO networks, there's a greater chance your dentist is in a DPPO.

5. Compare the features of the plans you're considering

Look at the premiums, deductible, coinsurance, and annual maximum and plan summary to understand all the plan's costs. Also, you should pay attention to things such as:

  • Types of services and treatments covered 
  • Waiting periods  
  • Primary dentist requirement  

If you're buying online, those types of details should be displayed in a simple and clear manner to help you make a well-informed choice.

Frequently asked questions about dental insurance

How does dental insurance work?

Like standard health insurance policies, you pay a monthly premium for dental coverage, and the insurance company helps pay for your care. However, since most dental service and treatment is preventive, dental insurance plans typically focus on preventive and basic procedures. While some basic entry-tier plans only cover that type of service, there are many top-tier full coverage dental plans that cover more costly procedures such as root canals and crowns.

What is the best dental insurance?

The best dental insurance for you is the plan that lets you see a dentist you like and trust, covers the treatments you and your family are likely to need, with premiums, coinsurance or  co-pays that work within your budget. Your best value may be a policy through work, but affordable plans with good coverage are also available to individuals.

What is traditional dental insurance?

Indemnity plans are sometimes called "traditional" dental insurance. These types of plans don't typically have a network. You can typically go to any dentist, and the insurance company reimburses a percentage of your dental expenses. Indemnity plans are becoming harder to find than DPPO and DHMO plans.

Can I purchase dental insurance on my own?

Yes. Individual and family dental policies can be very affordable, and major insurance carriers, such as Guardianmake it easy to shop for and compare plans online.

How much is dental insurance per month?

Rates vary by age and state, but as an example, a 40-year-old individual in New York can get a basic entry-tier plan for just over $20/month. A comprehensive top-tier plan with coverage for braces and major procedures can be purchased for just under $50/month.

Are dental plans worth the money?

Guardian claims data shows that dental plan members who received regular preventive care (i.e., received an oral exam and cleaning at least once a year) required less major dental services and, consequently, experienced lower out-of-pocket costs over a three-year period.

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Source: Guardian DTL Brief Ounce of Prevention Study, 2019

1 Last accessed July 2021

2Joseph R. Nemeth DDS & Associates Last accessed July 2021

3 "Stay in Good Company" Guardian Dental Health eBook, 2018

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