By: Dr. Elizabeth Eggert
Dental insurance can be a valuable tool in helping you manage the cost of maintaining a healthy smile. However, many patients are surprised to learn that dental insurance doesn’t always cover the full cost—or in some cases, any of the cost—of the treatments recommended by Dr. Elizabeth Eggert or Dr. Jeff Eggert of Eggert Family Dentistry. Understanding how dental insurance works, where coverage gaps occur, and why it’s worth investing in procedures not covered by your plan can help you make informed, confident decisions about your oral health.
How Dental Insurance Plans Work
Unlike medical insurance, dental insurance is designed more as a benefit than a comprehensive health care plan. Most dental plans follow a cost-sharing model between the insurer and patient, which includes deductibles, copays, annual maximums, and coinsurance.
- Deductible: A deductible is the amount you must pay out of pocket before your insurance begins covering costs. Preventive services like cleanings and exams often don’t require a deductible. But, unfortunately in this changing market, some new plans WILL require deductibles before they provide any benefits.
- Copay: A copay is a predetermined dollar amount that patients must pay upfront for a medical or dental service. These can vary depending on the type of service you receive.
- Annual Maximum: Most plans cap how much they’ll pay per year—commonly around $1,000–$1,500. Once you reach that limit, you pay for additional treatments out of pocket.
- Coinsurance: After meeting your deductible, you typically share in the cost of treatments. For example, your plan might cover 80% of a procedure, leaving you responsible for the remaining 20%.
At Eggert Family Dentistry, we do a lot to help you understand your insurance plan and how these terms apply to you. However, we always need you to understand that we have nothing to do with the makeup of your plan, we do not determine your coverage, and we cannot do anything to “make your insurance company pay.” Your plan is decided by the agreement between your employer and the insurance provider, or by the plan you purchase individually. As always, Dr. Elizabeth Eggert and Dr. Jeff Eggert may recommend a procedure because it’s best for your health, but that does not necessarily mean that you will have benefits from your insurance company for the procedure and your insurance may not agree to pay for it for you.
Why Doesn’t Insurance Cover Everything?
Most dental plans do not cover all procedures. Typically, they provide:
- 100% coverage for preventive care, such as exams, cleanings, and x-rays
- 80% coverage for basic procedures, such as fillings and simple extractions
- 50% coverage for major procedures, such as crowns, bridges, and dentures
Some procedures—such as dental implants, orthodontics, or cosmetic dentistry—may not be covered at all. Why? Insurance companies are a big business and many of them are out to maximize their profits. This means they often opt for the least expensive alternative treatment (LEAT). For example, Dr. Elizabeth Eggert or Dr. Jeff Eggert may recommend a dental implant for its durability and long-term benefits, but your plan might only cover a partial denture because it costs them less.
Other common coverage limitations include:
- Pre-existing conditions: Your plan might not cover treatments for conditions you had before enrollment.
- Frequency limits: Your plan may limit the number of times they will pay for a procedure, like cleanings or exams per year, even if you need more to keep your oral health in tip-top shape.
- Downcoding: Your insurance may change the procedure to a less expensive one, and you may be responsible for the difference.
- Bundling: Multiple procedures may be combined into one “bundle” by the insurer, reducing your benefits.
Remember: Your dental plan is a financial agreement, not a treatment guide. It’s designed to manage costs, not dictate what care you receive. The most accurate way to think of it is like a good pre-paid coupon.
What to Do if a Procedure Isn’t Covered
If Dr. Elizabeth Eggert or Dr. Jeff Eggert recommends a procedure that isn’t covered, you have a few options:
- Look for covered alternatives: Sometimes, there’s a less expensive procedure that may at least partially address your dental issue and is covered by insurance. However, cheaper isn’t always better. Discuss with Dr. Elizabeth Eggert or Dr. Jeff Eggert whether the alternative is a good fit for your situation.
- Ask us about payment options: At Eggert Family Dentistry, we want you to be able to receive the care you need. Please ask our business team about payment options, which can include credit cards or medical financing options like CareCredit, which let you spread out payments over time, often with little or no interest.
- Appeal insurance decisions: If a claim is denied because the procedure was deemed “not dentally necessary,” you can appeal. Kristina in our office works hard for you, appealing insurance company decisions every day. If she needs you to get involved, she’ll let you know and a phone call by you can also help move things along. Your insurance company wants to maintain a good relationship with you as you are their customer (often through your employer).
Ultimately, never skip a medically necessary procedure due to insurance limitations. Dental issues don’t resolve on their own—they worsen. Treating problems early can prevent pain, infection, and higher costs down the line.
Why Investing in Dental Procedures Is Worth It
While it’s natural to focus on cost and insurance coverage, sometimes it’s smarter—and more cost-effective—to invest in a procedure not fully covered by insurance. Here’s why:
- Durability: Procedures like dental implants may cost more upfront but last for decades, unlike dentures or bridges that may need to be replaced.
- Functionality: Higher-quality restorations often look, feel, and function like natural teeth, improving comfort and confidence.
- Preventive Value: Early treatment can stop issues from escalating, saving you time, money, and discomfort later. It is also less likely that you will need to have things replaced as quickly if done right the first time!
Make Treatment Decisions Based on Your Health, Not Just on Coverage
Dental insurance is a helpful tool, but it should not be the only factor in deciding your treatment. Your oral health has lifelong impacts on your comfort, nutrition, self-confidence, and even overall health. When facing a treatment decision, talk openly with Dr. Elizabeth Eggert or Dr. Jeff Eggert about your options, insurance coverage, and financing solutions.
Do you still have questions about what your plan covers or how to afford the treatment you need? Contact our team at Eggert Family Dentistry at 651.482.8412! We’re here to help you understand your options and get the care you need to stay healthy.
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