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Dental Insurance Limitations Explained

Dental Insurance Limitations Explained

When you enroll in a dental insurance plan, one thing that you know to expect is that their company will not pay for every dollar of every dental procedure that you ever have completed. The goal of insurance, after all, is to reduce your out of pocket expenses or surprise dental bills due to an unexpected emergency. Insurance companies have “limitations” to define what they don’t pay for, even if you’re covered under their plan for basic dental services. 

Exclusions on Certain Treatments 

Some dental procedures are completely excluded when it comes to what your insurance pays for. For instance, cosmetic treatment like veneers or teeth whitening are elective, and nearly all insurance plans exclude them from their list of covered services.

Another example of an excluded procedure might be treatment for an injury that occurred on the job, which should be covered under workers’ compensation benefits.

A fair number of exclusions are based on when the treatment is going to be performed, and other time requirements. Otherwise, if the procedure is not listed under your explanation of benefits, it is safe to assume that it will not be covered under your dental insurance policy.

Time Limitations

Your policy will dictate how often they will pay for a particular procedure to be performed. For instance, you may be permitted to have two dental cleanings per year, or one every six months. Having three cleanings per year or going every four months would mean that one of those cleanings isn’t covered at all.

Another common example is how often dental X-rays are taken. Maybe you had a full mouth series or “panoramic” film taken two years ago, but decided to change dentists. Your new dentist wants to take new X-rays, but your insurance policy says you’re only allowed one full series every three years. You’ll either have to pay for them on your own, or try to convince your new dentist to take the old X-rays (which can be challenging.)

The same goes for dental crowns. Even if you may really need a new one (say, if the old one broke or you got a new cavity around it,) your policy may only pay to replace it after five years have lapsed.

Time limitations leave you having to decide “do I really need this” or “am I willing to pay for this treatment out of pocket?” The bad thing is that if you wait too long, problems typically get worse (and more expensive to fix.) 

Waiting Periods

A waiting period is the time that’s required to pass after enrollment before you have a particular treatment covered. Usually it’s when subscribers are newer to their insurance plan, preventing them from having lots of expensive treatment performed up front. You may need to wait for six or even 12 months to pass by before you can file certain procedures toward your benefits.

Major services are usually the ones with waiting periods. These might include dental crowns, root canals, or how soon you can get an implant. If you just got on a new insurance plan in hopes to have necessary and expensive treatment completed, you may still have to wait several months before you can take advantage of the coverage. 

Age Restrictions

Preventive care can help adults and children avoid common dental diseases. But some types of procedures may not be covered on adults. It’s fairly common for dental insurance to cover treatments like dental sealants or fluoride, but only on children up to a certain age; it may be 12, 15, or even 18. Once a child passes that age, the service is no longer covered. 

Getting Better Dental Insurance Coverage

For people that have dental coverage through their employer, let the company’s human resources department know of any concerns in the plan when it comes to accessing care. The company can coordinate with the carrier to have a plan that’s beneficial to the majority of their employees.

If you need to buy separate coverage, or you don’t have dental insurance through your job at all, an affordable alternative to consider is a dental savings plan. These discount programs can save you 10-60% on most treatments, without an annual out-of-pocket limit.  A dental discount plan doesn’t usually have the same type of waiting periods as conventional insurance, so you can start saving right away. Contact the dental savings experts at to find a dental savings plan that fits your smile (and budget!)

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