How dental insurance works, in plain English

Medical insurance is built to protect you from a huge bill. Dental insurance is closer to a maintenance plan: it pays well for the care that prevents problems, pays part of the cost of fixing them, and stops paying at a fairly low yearly limit.

That design has two practical effects. First, preventive visits are usually the best value your plan offers, so use them. Second, for bigger work, the yearly maximum often matters more than the percentage.

An in-network dentist has signed an agreement with your insurance company to charge set fees for each service. You get those negotiated fees, and the plan pays its full share. An out-of-network dentist hasn't agreed to those fees, so the plan may pay less and you may owe the difference.

Soleil Dental Mesquite is in network with these PPO dental plans:

• Aetna
• Blue Cross Blue Shield
• Cigna
• Delta Dental
• Dentamax
• Guardian
• Humana
• MetLife
• United Concordia
• UnitedHealthcare

We have plan guides for Aetna, Blue Cross Blue Shield, Cigna, Delta Dental and MetLife. Plan names can be confusing, so if your card isn't on this list, or it says HMO or DHMO, call us and we'll check.

A PPO (preferred provider organization) plan lets you see any dentist, and costs you less when that dentist is in network. Most employer dental plans are PPOs.

A DHMO, or dental HMO, usually assigns you to one primary dentist from a list, often with set copays and little or no coverage outside that list. With one of these, you generally need to choose an office as your assigned dentist before the visit counts.

The plan type is usually printed on the card. When it isn't, the member services number on the back will tell you, or we can check for you.

Most plans sort care into three groups. A common pattern looks like this, but percentages vary from plan to plan, so treat it as a rough guide:

• Preventive: exams, cleanings and routine x-rays. Often covered at or near 100%, and often without a deductible.
• Basic: fillings, simple extractions, and on many plans deep cleanings and root canals. Often around 70 to 80% after the deductible.
• Major: crowns, bridges, dentures and sometimes implants. Often around 50% after the deductible.

Purely cosmetic care, like whitening, usually isn't covered. Orthodontics, including Invisalign, is often a separate benefit with its own lifetime maximum, when the plan includes it at all.

The annual maximum is the most your plan will pay in a benefit year. Once it's used up, you pay the rest until the plan resets. Many plans set it somewhere around one to two thousand dollars, which is why a root canal and a crown in the same year can use most of it.

A few things to know:

• The benefit year often starts January 1, but some plans run on a different calendar. Check yours.
• Unused benefits generally don't roll over.
• Depending on the plan, preventive visits may or may not count against the maximum.
• For larger treatment, splitting the work across the end of one benefit year and the start of the next can put two maximums to work. We'll tell you if that's an option and whether waiting is safe for your tooth.

The deductible is what you pay each year before the plan starts paying for basic and major care. It's usually a set amount per person, and preventive care often skips it.

Coinsurance is your share after the deductible. If the plan covers a filling at 80%, you pay the other 20% of the in-network fee. Some plans, especially DHMOs, use flat copays instead of percentages.

Put together: on a basic procedure early in the year, you'd typically pay any deductible you haven't met, then your coinsurance share of what's left. We show that math in your estimate, line by line, so you don't have to do it yourself.

Waiting periods are the most common surprise. Some plans, especially ones you buy on your own rather than through an employer, won't cover basic or major care until you've been enrolled for a while, sometimes several months, and sometimes up to a year for major work. Preventive care usually has no wait. Plans differ, so we check.

Other limits worth knowing about:

• Frequency limits: two cleanings a year, for example, or certain x-rays only every few years
• Missing tooth clause: some plans won't pay to replace a tooth that was already missing when you enrolled
• Replacement limits: a crown or denture may be covered only once every several years
• Downgrades: a plan may pay for a tooth-colored filling on a back tooth at the price of a silver one

None of this is a reason to skip care. It's a reason to know your numbers before you start, which is why we verify benefits and give you a written estimate first.

When you book, give us the subscriber's name and date of birth, the member ID, and the employer if it's a work plan. The front desk checks your coverage, your deductible, what's left of this year's maximum, and any waiting periods. If you need treatment, you get a written estimate that shows what the plan is expected to pay and what you'd owe. We file the claim for you.

An estimate is the best information available at the time. The plan makes the final decision when the claim is processed. For larger work, we can ask your plan for a pre-treatment estimate first.

We also help adult Medicaid patients use the services their plan covers. Call with your plan details and we'll check what applies to you.

The Sunshine Membership is our in-office plan for people without insurance. It's a $110 one-time fee with no monthly fees, and it includes 2 dental checkups with x-rays, unlimited limited exams for pain, and 30 to 40% off dental treatment. Cleanings aren't included, and pricing for cleanings varies. There's no insurance company in the middle, so there are no claim forms.

If you're comparing the membership with buying an individual dental plan, line up the plan's monthly premium, deductible, yearly maximum and waiting periods side by side. For someone who mostly needs checkups, or who needs major work soon and would be stuck in a waiting period, the membership is often the simpler choice. For larger or ongoing treatment, it's worth running both.

New patients without insurance can start with the $80 exam and x-rays. Sunbit and Cherry offer monthly payments on larger treatment, with or without insurance, and you can apply at the office.