Dental Insurance Knowledge

Apr 16, 2021

If you have a hard time understanding your dental insurance plan, we have put together this fact sheet of common dental insurance terms to help you understand better how your dental benefits work and the reimbursement process.

A dental plan is a means to help you to pay for your dental treatment. It is usually a policy that your employer has purchased for employees. If you have a dental plan, knowing how your plan works can help speed up the process and figure out how to get the most out of your coverage. We also recommend our patients to read the booklet or other materials available from their insurance provider.

Some things you need to know about your plan:

What is covered each year?
Is there a deductible?
What is the total maximum amount your insurer will pay per year?
What is co-payment?
To what extent am I covered for cleanings and X-rays?
To what extent am I covered for dental treatments such as fillings and root canals?
What about other treatments such as bridges and crowns, dentures and oral surgery?

What is covered each year?

A dental plan may operate within a calendar year, a benefit year or a school year if you are a college/university student in Ontario. A plan on a calendar year runs from January 1 to December 31. A plan on a benefit year runs for any 12-month period within the year.

There are several categories in a dental plan which are:

Basic: Routine dental procedures such as diagnostic test, X-rays, preventive hygiene visit, fillings, extractions
Major: Crown, bridge, denture
Endo: Root canal treatment
Perio: Gum/surrounding bone surgery
Ortho: Invisalign, traditional braces, ortho appliances

Usually, the coverage of each category is between 50%-100%. There is a total maximum amount your plan will pay per year for these categories, either by individual category or combined. Once the maximum amount is met, your dental insurance will not pay for any other dental services until a new calendar year/benefit year/school year starts.

Dental offices in Ontario follow the ODA fee guide. The fee guide is updated in yearly basis. It is important to check if your dental policy is based on the current fee guide. Some policies may pay to a previous year fee guide instead of the current fee guide.

Is there a deductible?

A deductible is the amount you must pay before your insurance carrier will begin paying for covered services. These usually range from $25 per person to $50 per family. For example, if your deductible is $25, you are responsible for paying for the first $25 of treatment each year to your dental provider. After that point, your dental insurance will apply up to the yearly maximum.

What is co-payment?

Your co-payment is the part of the bill you won't be reimbursed for (if the category is not covered at 100%).

To what extent am I covered for cleanings and X-rays?

Your cleaning visit is composed of several parts:

Recall exams: The recall exam or "check up" as most people call it, is an examination done by a dentist to an existing patient. The dentist checks the status of your oral cavity with/without updating X-rays (cavities, wearing off teeth, bone level, surrounding tissue, etc.) There is usually a limit on how often you can have a recall exam per year. The range is usually between 6 months to a year.
X-rays: X-rays are very important and more accurate to see what is going on inside the tooth and surrounding bone condition. Bitewing X-rays are used to check cavities and bone level. They are usually covered by your dental plan once every 12-18 months. A panoramic X-ray allows the dentist to view the anatomy of your head, neck, jaw and teeth in general. A full-mouth X-rays are images taken for each tooth. A panoramic and full-mouth X-rays are usually covered once every 3 to 5 years.
Scaling: This is when the dentist or hygienist removes all the harmful plaque and tartar (calculus) from your teeth surface above and below the gum line. Each unit is considered 15 minutes of time. Most adults use anywhere between two and a half to four units per visit depending on the condition in the mouth. Kids usually needs less units than adults. Most plans have between 8 and 16 units of scaling per year, and some plans have unlimited units.
Polishing: We use removes pumice to remove bacteria and stains from the surface of your teeth. The range is usually the same as the recall exam between 6 months to a year. Each unit is considered 15 minutes of time.
Fluoride: The range is usually between 6 months to a year, the same as your polishing and recall exams.

How Dundas Tomken Dental can help

We can assist in claiming your benefits. We also provide a complimentary insurance check for our patients before the dental appointment in case you have any questions regarding your dental coverage. We can help you estimate how much will be covered before starting your next treatment. We submit a pre-treatment plan to your dental plan administrator for a pre-determination of benefits. This is not a guarantee, but it does reduce the chances of your claim for reimbursement being limited or declined.

Thank you for choosing us for your dental needs. Let our team bring you a healthy smile.