What dental insurance actually covers - and the three procedures we always pre-authorize

Dental insurance is one of the most-misunderstood products in healthcare. The annual coverage maximum has not moved in twenty years, and the percentages on your benefits summary do not always match what you owe at checkout. We pulled together what we tell every new patient in their welcome packet so the math is clear before treatment, not after.

The three coverage tiers

Most dental plans organize procedures into three tiers, and the percentage of what insurance pays differs at each tier.

• Preventive (cleanings, exams, X-rays). Usually covered at 100%. Two cleanings and one set of X-rays per year is the typical allowance.
• Basic (fillings, simple extractions, periodontal scaling). Usually covered at 80%. You owe the remaining 20% at checkout.
• Major (crowns, bridges, root canals, dentures). Usually covered at 50%. You owe the other 50%, often after a deductible.

The annual coverage maximum on most plans is between $1,000 and $2,000. That cap was set in the 1970s and has not been adjusted for inflation. It is the number you should pay the most attention to on your benefits summary.

The number that actually matters

Your benefits summary will show "remaining annual maximum." That is the dollar amount your insurance will still pay this calendar year before the cap is hit. A crown that retails at $1,400 with 50% coverage means insurance pays $700 toward it - but only if you have $700 of remaining annual maximum. If you have already used $1,300 of a $1,500 cap on earlier treatment this year, insurance pays only $200 toward the crown and you owe $1,200.

This is why timing matters. A $2,500 treatment plan split across December and January often saves a patient hundreds of dollars by spreading across two annual maximums. Our treatment coordinator will always look at the calendar before scheduling major work.

The three procedures we always pre-authorize

For three categories of treatment we always submit a pre-authorization to insurance before scheduling. Pre-auth is a written commitment from your insurance carrier about exactly what they will pay. It is not legally binding, but it removes most of the at-checkout surprises.

• Crowns and bridges. Carriers occasionally downgrade a porcelain crown to a metal allowance. Pre-auth surfaces that before we cement anything.
• Periodontal (gum) treatment beyond a routine cleaning. Deep cleaning, scaling and root planing, and surgical periodontal procedures are often disputed by carriers and benefit from pre-auth documentation.
• Orthodontic treatment, including Invisalign. Pre-auth confirms lifetime ortho maximums and what counts toward them.

What we do not pre-authorize

Routine preventive visits, simple fillings, and small extractions are paid out predictably and pre-auth would slow scheduling without saving money. If you are unsure where your treatment lands, the front desk will tell you on the spot.

If you have a benefits summary you would like us to read before scheduling, the form at the top of the page accepts a PDF upload and we will walk through it with you.