Maximize Your Dental Benefits


We prefer the term dental benefits over dental insurance. It’s simple, insurance plans are designed to cover you in the event of a loss.

Your typical dental benefit plan is not designed to cover all dental procedures. And your coverage is not always based on the treatment you need or that your Gainesville dentist recommends.

Count on these dental benefits in our Gainesville dental office

We are in network with most PPO dental providers. The following are our accepted, in-network providers:

  • Aetna
  • American Dental
  • Assurant
  • BCBS Federal (group’s 104/105 and group’s 111/112)
  • Cigna PPO (out of network with DPPO Advantage)
  • Comp Benefits
  • Dearborn National
  • Delta Dental Premier
  • Eagles Benefits by Designs
  • Florida Combined Life
  • GEHA
  • Group Administrators
  • Guardian
  • Humana
  • Lincoln Financial
  • MetLife (PDP Plus)
  • Mutual of Omaha
  • Renaissance
  • Sun Life
  • UMR
  • Union Life
  • United Concordia (out of network with FED VIP plan)
  • United Healthcare

We do not participate in any HMO plans or any PPO Advantage, Indemnity, Pre-paid or Co-Payment plans.

How your dental benefits can improve your oral health

Your dental insurance coverage is useful motivation for prioritizing your oral health. Consistent dental check-ups help prevent issues such as cavities, extractions, root canals, oral cancer, and more that can increase your health risks and treatment costs.

You have more choices for dental coverage. Individual plans and dental benefits via your employer are options for reducing your out-of-pocket costs for treatment.

Common questions about dental benefits

Use your employer funded dental benefits plan if it’s available. If this is not an option consider the following as you compare your out-of-pocket costs with purchasing an individual plan:

  1. What is the plan’s premium?
  2. What is the plan’s deductible?
  3. What is your co-payment?
  4. What percentage of treatment costs (co-insurance) will you pay?

Also consider your frequency of dental appointments and the treatment you’ve received. Questions to consider include:

  1. Are you consistent with regular check-ups (two times per year)?
  2. Do you often require procedures following a check-up (e.g. dental fillings for cavities, etc.)?

Talk to your Gainesville dentist and our business team about your dental health history. Care frequency and changes in your dental health can have an impact on your benefits policy and renewal considerations.

Dental benefit plans may not cover all of your dental procedures. If applicable, consult your employer funded plan details or the coverage details outlined in your individual benefits plan.

Your Gainesville dentist will help assure that you’re maintaining your dental health. Keep in mind that some recommended treatment might not be covered.

Review your benefits coverage prior to scheduling. Ask us about your coverage options as well.

Most plans share the treatment costs with you. Think of percentages.

For example, your employer funded benefits plan will pay according to how much your employer pays into the plan. Your individual benefits plan will outline the payment percentages.

Avoid the temptation to base your dental care decision on benefit coverage. Less out-of-pocket doesn’t always lead to the healthiest option.

Before you commit to a benefits plan, understand how you and your plan will share treatment costs. Explore the following:

Your Deductibles

These are most often applied to all the services you receive. Deductibles must be paid before your plan coverage pays but remember that most plans don’t require a deductible for the preventive and diagnostic services you receive.;

Your Coinsurance

Coinsurance is the percentage of your dentist’s charges or the allowed benefit amount that you’re expected to pay. For example, your coverage plan might pay 80% and you would pay the remaining 20% that’s owed to your dentist.

Your Annual Maximums

This is the maximum dollar amount that your plan will pay during a year of coverage. You would pay any remaining charges over the maximum amount.

For example, if your annual premium is $1,500 and your charges for dental services top $3,500, you would be responsible for paying the difference of $2,000.

Stay aware of your plan’s maximum. If it’s too low for meeting your specific treatment needs ask your provider for a higher annual maximum.

And if your plan covers braces you will have a separate lifetime maximum limit.

Your Pre-Existing Conditions

Treatment might not be covered if you’ve had conditions prior to obtaining your current insurance plan. If so, you would be responsible for those treatment costs.

An example would be tooth replacement. If your tooth was missing prior to your coverage effective date your plan would not cover related treatment.

Your Fixed Dollar Amount (Capitation) Programs

You would pay a fixed amount for each dental visit or specific treatment. The remainder of your treatment costs would be covered by the program.

Should you choose a PPO or a DHMO? It’s overwhelming to review and select a dental insurance plan.

Here’s an overview that explains each type of plan and to help you decide.

Preferred Provider Organization (PPO)
This dental plan uses a network of dentists. Each have agreed to provide dental services for a set fee amount.

The number of provided services depends on the plan. If you see a dentist out of network while on a PPO plan you will most often have more out-of-pocket costs.

Dental Health Maintenance Organization (DHMO)
This plan resembles an HMO. Dentists in network are paid a set fee each month to provide dental services whether you see the dentist or not.

Covered services are most often provided at no cost to you. On occasion you could be required to pay out-of-pocket for a specific service.

Discount or Referral Dental Plans
Technically, these are not benefit plans. A company selling the plan would contract with a group of dentists who agree to discount their fees for service.

A discount would be applied to all services including cosmetic dentistry. The plans do not pay for any services and you would be required to pay the full cost for treatment at a reduce rate that’s determined by the specific plan.

Common questions you should ask before choosing a dental benefit plan.
It’s helpful to seek guidance from your dentist about your dental health status as you select a plan. Use the following questions to assess your dental needs and to choose the best plan for you:

  1. Can you choose the dentist you want?
  2. Will the plan cover treatment provided by a specialist?
  3. Are there any restrictions or limitations on coverage if you’re treated by a specialist?
  4. What are your total costs for the plan including the premium amount, co-payment amounts, co-insurance amounts, and deductible amounts?
  5. Is there a deductible amount and if so, how much is it and how is it applied?
  6. What is the annual maximum the plan will pay and is it an annual amount or a lifetime amount?
  7. Is there an out-of-pocket limit and if so, how much is it?
  8. What limitations does the plan place on your pre-existing conditions?
  9. Does the plan cover dental crowns, a root canal, oral surgery, and the treatment of periodontal (gum) disease? Are there any treatment related coverage limitations?
  10. Does the plan cover braces and are there any related limitations?
  11. Are dentures, dental bridges, and dental implants covered? Are there any related limitations to the coverage?
  12. Does the plan allow for dental emergency treatment? Are there any arrangements for a dental emergency when you’re away from home?

It’s possible. If this applies to you, what’s known as coordination of benefits (COB) can take place on your behalf.

Coordination of Benefits (COB)
Coordination of benefits determines which plan pays what for your dental care. Your benefits from each provider should not exceed 100% of the total charges.

When both of your plans have a COB clause the primary benefits plan is the one your employer provides or the one that considers you the main policy holder. The secondary plan is the one that considers you a dependent.

Consult your state laws and regulations to determine the coordination of benefits. If necessary, your plans will coordinate the benefits to eliminate overfilling or a duplication of benefits.

Another related question: When does your secondary plan pay?

The secondary plan will usually not accept a claim until the primary claim is paid.

Your secondary policy will often require a copy of your plan’s payment explanation or what’s known as an EOB (Explanation of Benefits).

How are your children covered? Your state laws or your dental plan will decide the policy that pays first for your dependents.

Your plan might use what’s known as the “birthday rule” (the spouse with a birthday occurring earlier in the calendar is the primary). Another plan might consider the father’s plan as primary.

And in the case of divorce or separation? The court’s ruling will decide who’s primary?

Dental benefits coverage can resemble piecing together a puzzle. Knowing the common terms used can help you see the big picture.

Annual Maximums”
This is the total dollar amount your dental plan will pay during a plan’s year. The final decision on the maximum payment amount is determined by your employer or the dental plan.

The annual maximum is typically $1,000 or $1,500. These figures have not changed much in the past 50 years.

These totals are applied to one person. Each of your family members will have a separate annual maximum and you’re responsible for the co-payments and any costs above the annual maximum.

Assignment of Benefits”
This occurs when you authorize the dental plan to forward payment for a covered procedure directly to your dentist who treated you.

Cost Sharing”
Your plan costs will be much less when the treatment cost is shared by the plan and those who are enrolled in it. There are different ways to share costs including deductibles, co-payments, frequency limitations, annual maximums, and the use of a fee schedule to calculate your benefit payments.

This is the out-of-pocket amount you must pay before your benefits plan will pay for any service you received. For example, if your deductible is $50, your plan will pay once you’ve paid $50 in related costs.

Your dental plan, like most, is based on a calendar year (January through December). You will pay the deductible amount once each year.

It could require more than one service or appointment to meet your entire deductible. Your plan will outline what services are applied to your deductible amount.

These are the dental services you receive that are not covered by your plan.

Frequency Limitations”
Your plan contains a list of conditions or circumstances that limit or exclude certain services from your coverage. Limitations determine how often a specific service is covered and are related to time or frequency (the number of procedures you’re allowed during a certain period).

For example, you could be allowed two teeth cleanings in a 12 months or one cleaning every six months.

Least Expensive Alternative Treatment (LEAT)”
Your plan will only pay for the least expensive treatment if you have more than one option to treat the condition.

Pre-existing Conditions”
Your plan can exclude conditions that you had prior to enrolling in the plan. For example, if you were missing a tooth prior to your coverage effective date your tooth replacement treatment will not be covered.

Approach your dental benefits with confidence. The following are dental terms paired with how they’re commonly mentioned:

Dental TermCommonly Known As
Amalgam RestorationSilver Filling
BruxismTooth Grinding
Composite RestorationTooth Colored Filling
EndodonticsRoot Canals
ExtractionTooth Removal
GingivitisEarly Gum Disease
Gingivoplasty/GingivectomyGum Surgery
Impacted ToothTooth Buried in Bone
Maxillofacial SurgeonOral Surgeon
Osseous SurgeryBone Surgery
Partial DentureRemovable Bridge
PeriodontitisAdvanced Gum Disease
ProphylaxisTeeth Cleaning
Scaling and Root PlaningDeep Cleaning
SealantsPlastic Coating on Teeth

Dental disease can affect you and your family’s overall health. Healthy teeth and gums rely on prioritizing check-ups and recommended treatment with your Gainesville dentist.

Dental plans for your children are required for new health insurance marketplaces under The Affordable Care Act. Adults are not required to have coverage though some state insurance marketplaces may provide you coverage as an adult.

The ACA prohibits dental plans from using annual or lifetime dollar maximums on dental coverage for your children. Pediatric dental benefits are no longer subject to caps on annual or lifetime maximums.

Since 2014, exclusions for pre-existing conditions are also eliminated under the ACA.  Your plan cannot deny you coverage because of a condition you had prior to enrollment in the plan.

Through the Health Insurance Marketplace you have the option of obtaining dental coverage as part of your medical coverage (pay one premium amount) or you can purchase a separate, stand-alone dental plan (and pay an additional premium amount).

California and other states include pediatric dental benefits in all medical plans. These states allow you to always have dental coverage through your medical plan and have the option of purchasing additional coverage through a stand-alone plan.

Other states, such as Washington, only allow you to obtain pediatric dental benefits coverage through a stand-alone dental plan.

The high option dental plan has a higher premium with lower co-payments. You will pay more on a monthly basis and less when you use your dental services.

The low option plan has a lower premium with higher co-payments and deductibles. You will pay less on a monthly basis and more when you use your dental services.

Dental plans are not designed to cover all of your dental procedures. You could be required to share the costs for procedures that are not covered at 100%.

Out-of-pocket costs such as deductibles and co-insurance can assist with portions of those uncovered costs.

A dental plan purchased separately from your medical plan can require you to pay a separate out-of-pocket maximum that applies to your children’s stand-alone dental plan. Your out-of-pocket limit is defined as the total amount you will pay for your dental care including deductibles, co-insurance, and co-payments.

Your out-of-pocket maximum for one child is $350 and is $700 for two or more children. Once you reach this amount the dental plan must pay for all additional covered expenses for the remainder of the plan year.

Visit to choose the resource that helps with your decision.

Contact our Gainesville dental office about your dental benefits coverage and related questions.