Choose Smart California: The Ins and Outs of Dental Coverage

My Patient Rights > Choose Smart California: The Ins and Outs of Dental Coverage

Choose Smart California: The Ins and Outs of Dental Coverage

So far, we’ve reviewed key terms you should familiarize yourself with as you shop around for health plans during Open Enrollment and we developed a guide to help you choose a plan that is right for you. This week, we’re diving into dental coverage. After all, taking care of your health requires a holistic approach and dental care should never fall off of your radar.

While you can buy dental – or vision – insurance year round, you should note that there are some plans you can only buy during open enrollment, especially if you’re adding or bundling them with your general health insurance package. In this post, we’re going to walk you through some of the basics to consider when purchasing a dental plan.

First, let’s start off with the types of dental plans and how they differ from one another:

  • Dental HMO: This plan requires you stay in-network to receive services, but doesn’t have any deductibles or maximums, and out-of-pocket costs come from copays. Your primary dentist must refer you to specialists, such as orthodontists, before you visit for a treatment. This plan also does not have a wait time before coverage kicks in when you apply.
  • Dental PPO: This plan allows you to see both in-network and out-of-network dentists, as well as dental specialists. The caveat with this plan is that, as a new member, there may be a waiting period before your insurer covers specialized treatments such as bridges and crowns. Additionally, PPO plans do require you to meet a deductible and have an annual maximum amount of coverage. However, out-of-pocket costs may be lower than those for an HMO plan.
  • Fee-for-service: This plan is similar to a PPO plan as it requires you to pay co-insurance (your out-of-pocket costs when you get a service that your insurer doesn’t cover), meet a deductible and have an annual maximum amount of coverage. The plan differs from a PPO as fees are not reimbursed at the same rate as a PPO. However, this plan offers the greatest choice of dentists.

A key difference between health plans and dental plans are how the costs are distributed. While health insurance plans will outline your maximum out-of-pocket costs, most dental plans will put a cap on how much they will pay for services in a year.

Cost savings are usually distributed by a 100-80-50 rule. This rule determines a dental plan’s contract allowance and what they will reimburse based on the types of services received.

Here is what that looks like:

  • Preventive: Your insurers will typically cover 100% of costs associated with preventative care, including routine cleanings, checkup, and some x-rays.
  • Basic: Costs for basic services like fillings, deep cleanings, and extractions will normally be 80% covered by your insurer.
  • Major: Larger operations like root canals, crowns, dentures, etc. may be about 50% covered by your insurer.

When reviewing plans, you should determine the max cost your insurer will cover. Some range from $750 to $1,500 but others don’t have an annual maximum at all. So keep in mind that while preventative procedures like cleanings will typically be covered, services like root canals may lead to high costs, which can lead to you maxing out your total “allowance” in just one visit.

Choosing a dental plan is not all-too-different than choosing a health plan, but is equally important. While we haven’t covered all the elements of choosing a dental plan that is right for you, Delta Dental’s 9-point checklist can help you get answers and additional guidance on selecting a plan.

My Patient Rights is here to help during Open Enrollment – and every day!

Share Your

My Patient Rights can help guide you in resolving issues so you can get the health care you deserve.


Find answers to commonly asked questions.

Know Your Rights

State and federal law protects your rights. When you sign up for a health plan and/or if you have problems accessing care through your health plan, it is important to know your rights.