Even for covered services, most plans share the costs of treatment with you. If you have benefits through work, the amount is determined by how much your employer pays into the plan. If you have an individual plan, the terms will be spelled out in a contract.
Although you may be tempted to make dental care decisions based on what your plan will pay, the least expensive option is not always the healthiest option. Before committing to a plan, make sure you understand how you and your plan share costs. This is done in several ways:
A deductible is typically applied to all services and must be paid by you before your plan coverage starts to pay. Most plans don’t require a deductible for preventive and diagnostic services.
In most cases, you will be expected to pay a percentage of the dentist’s charges or allowed benefit amount. This is called coinsurance. For example, your plan may pay 80% and you pay the remaining 20% owed to your dentist.
This is the maximum dollar amount a plan will pay during the course of the plan year. You pay anything over that dollar amount. For example, if your annual maximum is $1,500 and your dental expenses top $3,500, you are responsible for that additional $2,000. If the annual maximum of your plan is too low to meet your specific needs, you may want to ask the plan how you can get a higher annual maximum.
Also, if your plan covers braces, there is usually a separate lifetime maximum limit.
Your dental plan may not cover conditions you had before enrolling even through treatment may still be necessary. You would be responsible for paying these costs. For example, benefits may not be paid for replacing a tooth that was missing before the effective date of coverage.
Fixed Dollar Amount (Capitation) Programs
In these programs, you pay a fixed dollar amount for each dental visit or specific treatment. The rest of the treatment cost is covered by the program.