There is a fundamental difference between how medical and dental insurance policies work, although they look outwardly similar: you pay a monthly premium for a coverage.
Most dental policies emphasize prevention and diagnostics, typically covering two annual exams and cleanings, plus X-rays and, for children and older adults, fluoride treatments etc.
Most medical policies (of the PPO type) also cover preventative annual physical examination, but really step up the coverage for those unlikely medical situations that exceed your annual deductible.
On the other hand, dental insurances commonly have what is described as “100-80-50” coverage, meaning it pays 100 percent of the cost of routine preventive and diagnostic care, such as checkups and cleanings; covers 80 percent for fillings, root canals and other basic procedures; and 50 percent for crowns, bridges, implants, surgeries and other major procedures. Most plans also limit the total of their coverage at about $1,000-$1,500 a year.
The more extensive dental treatment you need, the less of it will be covered.
The major procedures coverage can be quite restrictive based on the protocols of your insurance company. For example, your insurance company may refuse to cover the cost of a dental implant because it deems a bridge or a denture to be an acceptable alternative treatment.
So, while your dentist will work with your insurance to maximize your coverage, including submitting additional explanations and expert testimony, the dental insurance companies ultimately do limit their payouts.
A couple words about so-called CDT (Current Dental Terminology) codes. You probably think of your dental needs as one big procedure, but insurance companies require your dentist to submit very detailed itemization of all the diagnostics and work performed. Because of that, when you read your EOB (Explanation Of Benefits) or a treatment plan, it might have line items that you don't immediately recognize.
The benefits determination from your insurance company should not be the dominant factor in your decision about how to protect your own body. While most dental treatments are not life-or-death situations, having a healthy mouth will go a long way towards building a healthy body and a healthy spirit.
The HMO (Health Maintenance Organization) option restricts coverage to dental professionals within a limited network. Typically your in-network "general practicioner" dentist will determine the type of specialist care your policy covers.
