Dental Insurance Plans : What’s covered and what’s not? In Network vs Out of Network.

Dental Insurance Plans : What’s covered and what’s not? In Network vs Out of Network.

Dental Insurance Plans explained

So one of the most frequent question I get asked in the office is, “Does my insurance cover that?”. Well, let’s find out what’s covered and what’s not. I will show you several types of insurances our office sees,  and the benefit of seeing an in network (IN) dentist vs out of network (OON) Dentist.

Insurance coverage for PPO (preferred provider organization) Plans.






















After you give us your insurance information, we would verify your insurance coverage. The chart above is an example of what I would get from the insurance, it has some of the most common dental procedures listed. The person in this particular example is a metal worker for a local Union, with Delta PPO of Illinois. By all measures, this is type of insurance provided by the Union/employer is the most common, and considered “good” insurance by many.

Upon closer inspection, you can see that most procedures are covered at 50%. Only a few procedures are covered at 100% such as : Exams, X-Rays, and basic cleanings. Speaking from personal experience, 90% of the patient over age of 30 have some type of periodontal disease that would require a deep cleaning (50% coverage).

Dental fillings are usually covered at 80% with PPO insurances.

Ok, but what are star asterisks next to the insurance break down you ask? Some insurances has waiting period in place before you could use the benefit for certain procedures, they want you to pay the premiums for a year before you could become eligible for coverage.

There’s typically a deductible patient has to pay every year if he/she needed work done, $50 is a very common deductible amount, I’ve seen anywhere from $0-$125 deductibles in my office.

But wait, there’s more. A very typical PPO insurance has annual maximum anywhere between $1000-$2000. In today’s market, that’s roughly 50% coverage for ONE TOOTH that needs a major restoration (ie root canal/crown, implant).

In Network (IN) vs Out of Net Work (OON)

“Do you take my insurance?” is another commonly asked question, the answer is yes, any dentist can take your insurance. The difference is in the fees.

In network dentist has contract with the insurance company to provide services at a negotiated fee. OON dentist CAN charge whatever they want for their service, and often, OON dentists charge similar or lower fees than in network dentists.  That’s about the only difference.  Find a dentist that you’re comfortable with, even if he/she is out of network.

What if I have Medicaid?

Medicaid covers procedures at 100% for obvious reasons, but the major drawback of Medicaid is that, only limited procedures are covered. In the state of Illinois, Medicaid basically only cover 4 things, cleaning, fillings, extraction, and complete dentures at very reduced fees to the dentist. To be fair, they also provide coverage for root canal of front 6 teeth, and crowns with non noble metal base, but fees are reimbursed at even more ridiculously low levels, a dentist would not be able to stay in business doing root canal/crowns for Medicaid patients.

If you need root canal of the back teeth, or have no teeth in the first place, you’re out of luck. Tooth replacement option for Medicaid is basically non existent. Bridge, Partials, and Implants are not covered. I’ve seen countless patients with no back teeth to eat with, had elected to get all their front teeth pulled just so they could qualify for a complete denture.

This places a huge dilemma on the part of the dentist. Now imagine that you have a compound fracture in one leg, your orthopedic surgeon tells you that the insurance does not cover the reconstructive surgery to repair the leg, but it does cover for a wheel chair only if you have no legs, would you get both legs amputated just to get a wheel chair?

In conclusion…

Hopefully by now, I dispelled you from the idea that your dental insurance covers much of anything, it’s more of an assisted program.  The best dental insurance is to brush and floss daily with fluoridated toothpaste. If you have any questions about your dental insurance feel free to call our office. Book an Appointment