Fillings: Dental Insurance Coverage

Dental insurance is designed to help you maintain good oral health by covering the cost of dental care. Most dental insurance policies cover regular check-ups and cleanings twice a year, and some will also cover the majority of expenses related to cavity fillings. However, different dental policies may cover some types of fillings and not others. For example, most insurance plans will cover fillings with amalgam (silver) but not composite (tooth-coloured) fillings. This is because composite fillings are considered a want rather than a need, and amalgam fillings are cheaper and easier to use.

Amalgam vs composite fillings

When it comes to dental fillings, amalgam and composite fillings are two of the most common types. Both types of fillings have their own advantages and disadvantages, and the best choice depends on factors such as dental history, budget, and personal preferences. Here is a detailed comparison between amalgam and composite fillings to help you understand the differences and make an informed decision:

Amalgam Fillings

Amalgam fillings, often referred to as silver fillings, have been used for over 150 years. They are made of a combination of metals, including silver, tin, copper, and mercury. Here are the pros and cons of amalgam fillings:

Advantages of Amalgam Fillings:

• Highly durable and long-lasting, with a lifespan of 10 to 15 years or more with proper care.
• Withstand strong chewing forces, making them suitable for back teeth.
• More affordable compared to composite and gold fillings.
• Modern versions have minimal mercury exposure risks.

Disadvantages of Amalgam Fillings:

• May discolour surrounding teeth and require the removal of healthy tooth structure.
• Can expand and contract with temperature changes, leading to potential cracks and fractures.
• More noticeable, even on back teeth.
• Some dentists no longer perform amalgam fillings due to safety concerns.

Composite Fillings

Composite fillings, also known as tooth-coloured fillings, are a newer alternative to amalgam. They are made of a composite resin material that can be customised to match the colour of the patient's teeth. Here are the pros and cons of composite fillings:

Advantages of Composite Fillings:

• Natural appearance that blends seamlessly with surrounding teeth, making them hard to detect.
• Durable and fracture-resistant, ideal for small to medium-sized cavities.
• Not affected by temperature changes, reducing the risk of cracks and tooth decay.
• Can be used to fix minor cosmetic flaws.
• Require less drilling and are ideal for smaller restorations.

Disadvantages of Composite Fillings:

• Shorter lifespan compared to amalgam, typically lasting 5 to 10 years.
• More expensive and may not be as cost-effective in the long run.
• Placement takes longer, which may be a concern for patients with dental anxiety or special needs.
• Prone to discoloration over time, requiring replacement.

Choosing the Right Filling Type:

When choosing the right filling type, it is essential to consider factors such as the location of the decay, your medical history, aesthetic needs, and cost. Consult with your dentist to weigh the pros and cons of each option and make an informed decision based on your specific needs.

Dental insurance plans

Dental insurance is an important consideration for maintaining oral health, which in turn impacts overall health and wellness. While dental and vision insurance are not covered by standard individual or family insurance healthcare plans, dental insurance can be purchased separately or as part of an employer-sponsored health plan. This makes dental insurance accessible to individuals, families, and businesses alike.

Dental plans typically fall into three categories: employer-based, self-purchased, or "riders" attached to medical insurance policies. The right dental insurance policy can help with the high cost of dental work, covering anything from routine exams and cleanings to more complex procedures such as root canals and extractions.

Preferred Provider Organization (PPO)

PPO plans come with a list of dentists and other oral health care providers that accept the plan, known as in-network providers. Going to an in-network provider will result in the lowest out-of-pocket cost for the patient. Using an out-of-network provider is usually an option, but the out-of-pocket costs will be higher.

Dental Health Maintenance Organization (DHMO)

DHMO plans provide a network of dentists that accept the plan for a set co-pay or no fee at all. However, seeing an out-of-network dentist may not be an option, and if you do, you may have to pay the full amount yourself.

Discount or Referral Dental Plan

This type of plan offers a discount on dental services from a select group of dentists. Unlike health insurance, this type of plan doesn't pay for any of the care. Instead, the dentists who participate agree to give discounts for the care received.

Private Dental Insurance

Private dental insurance is purchased individually, not through an employer. It can be bought directly from a dental insurer, HealthCare.gov, or an insurance broker.

Direct Reimbursement Programs

Direct reimbursement programs pay a predetermined percentage of the total amount spent on dental care, regardless of the treatment category. This type of program typically doesn't exclude coverage based on the type of treatment and allows the patient to choose their dentist.

"Usual, Customary, and Reasonable" (UCR) Programs

UCR programs usually allow patients to choose their dentist. These plans pay a set percentage of the dentist's fee or the plan administrator's "reasonable" or "customary" fee limit, whichever is less.

Table or Schedule of Allowance Programs

These programs provide a list of covered services with an assigned dollar amount that the plan will pay, regardless of the fee charged by the dentist. The patient is then billed for the difference, known as balance billing.

Capitation Programs

Capitation programs pay contracted dentists a fixed amount, usually monthly, for each enrolled family or patient. In return, these dentists agree to provide specific types of treatment at no charge. For some treatments, a co-payment may be required.

Indemnity Dental Insurance Plans

Indemnity dental insurance plans, also known as traditional or fee-for-service dental plans, offer flexibility and a straightforward reimbursement model. Patients can visit any dentist they choose and pay the dentist directly, then submit a claim to the insurance company for reimbursement.

Dental Insurance for Seniors and Low-Income Residents

Government-funded health insurance plans, such as Medicare and Medicaid, may provide dental coverage for seniors and those who meet certain low-income and resource requirements. However, Medicare typically doesn't cover routine dental services, and most state Medicaid programs only cover dental care for children.

Dental Insurance for Children

Dental benefits are considered an essential health benefit for children, so if a health plan covers dependents aged 18 and younger, it is required by law to include dental benefits.

Composite vs Amalgam Fillings

It is important to note that while most dental insurance plans cover fillings, there are different types of fillings, and coverage may vary. Composite fillings, also known as "white" fillings, are made of a strong resin material that matches the natural tooth shade. Amalgam fillings, on the other hand, are silver in colour. Composite fillings are often preferred for aesthetic reasons, but they may not be covered by insurance as they are not considered a necessity. Amalgam fillings, which can fill cavities just as effectively, are usually covered.

Basic dental coverage

Preventive Dental Care

Basic Restorative Procedures

In addition to preventive care, basic dental coverage extends to common restorative procedures. Fillings are a fundamental aspect of this coverage. Most dental insurance plans will cover fillings, especially those related to cavity treatment. Root canals and tooth extractions are also typically included in basic coverage. These procedures help address issues like cavities, tooth decay, and infections.

Cost Considerations

While basic dental coverage provides essential benefits, it's important to understand the associated costs. Basic procedures, such as fillings, are usually covered at a lower percentage compared to preventive care. For example, an insurance plan may cover 80% of the cost of a filling, leaving the policyholder responsible for the remaining 20% after meeting the annual deductible. This is an important factor to consider when choosing a dental insurance plan.

Composite vs. Amalgam Fillings

It's worth noting that insurance coverage for fillings may vary depending on the type of filling. Composite fillings, also known as "white" or tooth-colored fillings, are often not covered by insurance plans because they are considered aesthetic or elective. On the other hand, amalgam (silver) fillings are typically covered since they are more affordable and widely used. If you prefer composite fillings, you may need to pay extra or upgrade your insurance plan.

Plan Variations

Dental insurance costs

The cost of dental insurance varies depending on several factors, such as the type of plan, the insurance provider, and the location. On average, individual dental insurance plans can range from $8.95 to $50 per month, while family plans may cost between $50 and $150 per month.

Dental insurance premiums can range from $20 to $50 per month, and you may be required to meet a deductible before the benefits kick in. The deductible is the amount of money that must be paid before any dental insurance benefits apply.

The cost structure of dental insurance plans can include premiums, copays, coinsurance, deductibles, and annual maximums. The premium is a monthly amount paid by the individual or their employer for insurance. The premium amount can vary between insurance companies and plans, typically ranging from $20 to $50 per month for an individual or $50 to $150 per month for a family.

The copay is the amount paid for a dental treatment or service. Once the copay is paid, insurance will typically cover the remaining cost. Many dental insurance plans also require a deductible, which is the amount of money that must be paid before insurance benefits begin.

Coinsurance determines the percentage of the dental service covered by insurance. For example, if the insurance coinsurance is 90%, the insurance company will pay 90%, and the individual will pay the remaining 10% of the covered charges.

The annual maximum is the total amount that insurance will pay each year, limiting coverage in a given year. Some dental plans do not have annual maximums.

Dental plans can be categorized into two main types: indemnity plans and managed-care plans. Indemnity plans, often referred to as "fee-for-service" plans, offer a broad choice of dental care providers and typically involve the policyholder paying upfront and being reimbursed a portion of the cost. Managed-care plans include Dental Health Maintenance Organizations (DHMOs) and Preferred Provider Organizations (PPOs), which usually limit provider choices to a network of dentists who offer services at lower costs.

PPO plans offer a blend of flexibility and cost management, making them a popular choice. Policyholders can choose any dentist but receive greater benefits and lower out-of-pocket costs when using in-network providers. PPO plans typically involve deductibles, co-pays, and co-insurance, with an annual maximum benefit limit.

HMO plans are ideal for individuals who prioritize lower costs and are comfortable receiving care from a specified network of providers. These plans usually involve lower premiums and minimal or no deductibles, but they typically do not cover out-of-network services, resulting in higher out-of-pocket costs when receiving care outside the network.

Dental insurance is designed to help individuals manage the costs of routine dental care, such as cleanings, exams, and fillings, and more complex procedures. It is worth considering dental coverage to maintain oral health and prevent dental hygiene problems that can impact overall health.

Full coverage dental insurance

• Preventive care: Regular dental exams, cleanings, X-rays, and fluoride treatments.
• Basic restorative care: Fillings, extractions, and non-routine X-rays.
• Major restorative care: Bridges, crowns, and dentures.
• Orthodontic treatment: Braces, aligners, and space maintainers.

It's important to note that full coverage does not mean that the plan covers 100% of all costs. There are usually out-of-pocket expenses, such as deductibles, copays, and coinsurance, that the insured person is responsible for.

Types of Full Coverage Dental Plans

There are several types of full coverage dental plans available:

• Dental PPO (DPPO): Offers a wide range of provider choices and may cover a broad range of dental services. However, costs can vary between providers and may include deductibles, copays, and coinsurance.
• Dental HMO (DHMO): Typically has lower premiums and fewer out-of-pocket costs. However, you may be limited to a specific network of dentists and have to obtain services from a designated Primary Care Provider.
• Dental EPO (DEPO) and Dental POS (DPOS): May also provide coverage for a wide range of dental services but can differ in covered services, costs, and limitations between carriers.

Cost of Full Coverage Dental Insurance

The cost of full coverage dental insurance can vary depending on the specific plan chosen and the number of people covered. Some factors that can influence the cost include:

• Deductible: The amount paid before the plan starts paying.
• Coinsurance: The percentage of costs shared between the insured and the plan, typically after meeting the deductible.
• Copay: A flat fee paid per visit or procedure.
• Annual Maximum: The maximum amount the plan will pay toward dental care in a plan year.
• Premium: The monthly payment for the plan, which can be higher for plans with more provider choices and lower for plans with limited choices.

Choosing a Full Coverage Dental Plan

When choosing a full coverage dental plan, it's important to consider your current and future dental needs, your budget, and whether your preferred dentist is in the plan's network. Reading the fine print and understanding the coverage limits, exclusions, and waiting periods is crucial before enrolling in any dental coverage plan.

Frequently asked questions