How Dental Plans Differ from Medical Plans

January 24, 2019

Most medical insurance plans don’t cover dental care, so for that you need a separate dental plan. If you have a dental plan, it’s important to know how it’s similar to a medical plan—and how it’s different.

One way dental plans are like medical plans is that they both use cost sharing. That means you pay part of the cost and the plan pays part. Your part of the cost can take the form of coinsurance, copays, deductibles or other cost-sharing concepts. Like medical plans, most dental plans have a network. A dental network is a group of contracted providers that offer discounted services based on rates negotiated in advance by the plan.

Classes of Service

Unlike medical plans, most dental plans pay for care based on the “class of service” your treatment falls into. How much they pay depends on the type of service you receive. Different plans may pay different percentages. Orthodontics (such as braces) may or may not be covered by the dental plan.

The classes of service are:

• Class I: Diagnostic and preventive care such as cleanings, exams and X-rays. In-network services are usually covered in full (100 percent of the acceptable charge).
• Class II: Basic restorative care such as fillings, periodontal work and root canals are typically reimbursed at a lower rate (generally 80 percent of the acceptable charge).
• Class III: Major restorative care such as crowns, bridges and dentures are often covered at 50 percent of the acceptable charge.
• Class IV: Orthodontia (braces). If your plan covers orthodontia, coverage may be limited to plan members under 19. These services usually have a lifetime maximum benefit that applies to the entire course of treatment instead of an annual maximum. The services are usually reimbursed at 50 percent up to the lifetime maximum.

Coverage Limits

Another way in which dental plans can differ from medical plans is that they usually have an annual coverage limit. Dental plans generally set a dollar limit on the amount they’ll spend for your dental care in one year. (A separate limit applies to orthodontics, if it’s covered by the plan.)

There may be other limits as well in a dental plan. Plans may limit the number of preventive services you receive in a year, like cleanings and diagnostic services such as exams and X-rays (frequency limits). There may also be limits on how often crowns, implants, bridges and dentures can be replaced (replacement limits). There may also be a situation in which the plan offers a less expensive service option for you when you get care. For instance, they may offer a benefit for a silver filling when you’re getting the white (tooth-colored) filling on a back tooth. Your out-of-pocket expense if you get the white filling would be more than the 20 percent defined by the plan.

Planning for Dental Care

If you need dental care and want to plan for the costs, you can use FAIR Health’s free Dental Cost Lookup Tool. It will give you an estimate of how much dental treatments may cost in your location.

For more information on dental health insurance, see our articles on Dental Plans and Dental Coverage for Children.