The three tiers: preventive, basic and major
Almost every plan sorts treatments into three groups and pays a different percentage for each. That structure explains why a cleaning is free and a crown is not.
- Preventive. Cleanings, checkups and routine x-rays. This is what most plans cover in full from day one, because the insurer wants you to go.
- Basic. Fillings, simple extractions, gum treatment. Here you pay a share, and there is usually a short waiting period.
- Major. Crowns, root canals, bridges, dentures, implants. The least covered tier and the one with the longest wait.
How to read a plan in thirty seconds
Look for three numbers in a row, something like 100 / 80 / 50. That is what the plan covers for preventive, basic and major. If the third one is low and the wait is long on top of that, that plan is not built for major work you already know you need.
Waiting periods decide whether the plan works for you
A waiting period is the time between your plan starting and your being able to use a given benefit. It is not fine print with bad intentions: it is what stops someone from signing up Monday and getting a crown Tuesday.
It works in tiers. Cleanings are usually available right away. Basic care after a few months. Major care has the longest wait, which in many plans runs six to twelve months.
Say it up front
If you already have work pending, telling me does not count against you: it is what lets me rule out the plans that will not help and look for ones with short waits or none at all.
PPO, DHMO and discount plans are not the same thing
Three very different products get sold with the same language, and the third one causes the most confusion among the families I work with.
- PPO. A wide network and you can see any dentist, though you pay less in network. It usually has a deductible, coinsurance and an annual maximum.
- DHMO. You pick a main dentist inside a specific network and pay a set fee per treatment, with no deductible and often no maximum. Cheaper, considerably less flexible.
- Discount plan. This is not insurance. You pay a fee to access a list of reduced prices and then pay the full treatment at that price. Nobody covers a percentage for you.
A discount plan can make sense in specific cases, but you should know what you are buying. If someone presents it to you as dental insurance, that alone tells you a lot about who you are talking to.
The annual maximum, the deductible and vision
Three details almost nobody checks when comparing, and they decide what you really pay in a year with treatment.
- Annual maximum. The most the plan pays in a year. It is the opposite of a health plan's out-of-pocket limit: here, once it runs out, you start paying everything.
- Deductible. What you pay before the plan starts covering. It normally does not apply to preventive care, which stays free from day one.
- Vision. When it is included, it usually covers an annual exam and an allowance toward lenses or frames. It is a separate benefit with its own limits.
The question that sorts everything
Before looking at prices, decide whether what you want is maintenance, meaning cleanings and checkups so you never reach a problem, or whether you already have specific work ahead. Those are two different searches and they lead to different plans.
