Health insurance plans rarely cover dental issues. For that, you need a separate dental insurance policy. Health insurance plans cost more, but provide much more extensive coverage for medical issues. Dental insurance plans are less expensive, but offer less coverage, with limits on how much they pay per year. By understanding the differences, you can find the right combination for your needs.
Health Insurance vs. Dental Insurance: An Overview
Health insurance is a contract between you and the insurer. You pay a premium and the health insurance company pays certain medical costs. This type of coverage focuses on unexpected medical needs, but does not cover most oral health issues.
On the other hand, dental insurance, a more recent innovation, focuses on oral health. A dental policy helps pay for preventive oral health care (such as teeth cleaning, examinations, and X-rays), as well as services such as fillings and root canals. Coverage for non-preventive services tends to be low, as do dental insurance premiums.
“While overlapping in some cost coverage areas, health and dental insurance differ fundamentally in scope and structure,” said Samuel Green, founder and CEO of Blue Insurance. “Health plans encompass a wider range of medical services from hospitals, physicians, labs, and pharmacies, with cost sharing through deductibles, coinsurance, and copays. Dental focuses narrowly on routine oral exams, cleanings, X-rays, fillings, crowns, and tooth extractions tied to set copays or discounts from in-network dentists.”
Key Takeaways
- Insurers offer different types of dental insurance and health insurance plans.
- The Affordable Care Act defines which essential benefits all health plans must include.
- Dental insurance and health insurance require you to pay several types of costs.
- Health insurance limits your maximum annual spending, while dental insurance does not.
- Both types of insurance may impose waiting periods
Health Insurance vs. Dental Insurance: Similarities and Differences
Before we get into the nuts and bolts of how dental insurance and health insurance work, let’s see how certain policy factors compare and differ.
| Dental Insurance | Health Insurance | |
|---|---|---|
| Types of plans | HMOs, PPOs, indemnity plans, dental savings plans | HMOs, PPOs, indemnity plans |
| Where to get plans | Commercial insurance market, employer, government-sponsored marketplace | Commercial insurance market, employer, government-sponsored marketplace |
| Policy costs | Premiums, deductibles, coinsurance, copayments | Premiums, deductibles, coinsurance, copayments |
| Annual coverage maximum | Yes | No |
| Out-of-pocket maximums | No | Yes |
| Waiting period | Some policies | Some policies |
| Covered services | Ambulatory (outpatient) care; Emergency care; Hospitalization; Laboratory services; Maternity services, including pregnancy and newborn care; Mental health care, including behavioral health and substance abuse treatments; Prescription medications; Preventive and wellness care, including chronic disease management; Rehabilitative and habilitative care, including devices required due to chronic conditions, disabilities, or injuries; Pediatric care, including oral and vision services | Preventive and restorative care, including but not limited to: Cleanings, Exams, X-rays, Fluoride treatments, Fillings, Bridges, Crowns, Dentures, Root canals, Extractions, and Implants |
Health Insurance
How Does Health Insurance Work?
“Health insurance covers a portion of costs for approved medical services after members meet annual deductible amounts,” Green explained. “Insurers contract set rates with doctors, facilities, and pharmacies within networks. Remaining costs are paid by coinsurance or fixed dollar copays per service. Total out-of-pocket costs are capped annually.”
Health insurance requires you to pay a monthly premium to the provider. If you have an employer-sponsored policy, your employer may contribute to the premium payment. In return, the insurance company pays some of your medical costs.
Health insurance plans require you to seek care within certain guidelines. For example, a plan might require you to get all your care through a network of participating doctors, hospitals, and specialists.
What Does Health Insurance Cover?
The Affordable Care Act (ACA) established 10 essential health benefits that all health insurance policies must cover:
- Ambulatory (outpatient) care
- Emergency care
- Hospitalization
- Laboratory services
- Maternity services, including pregnancy and newborn care
- Mental health care, including behavioral health and substance abuse treatments
- Prescription medications
- Preventive and wellness care, including chronic disease management
- Rehabilitative and habilitative care, including devices required due to chronic conditions, disabilities, or injuries
- Pediatric care, including oral and vision services
The ACA does not define dental and vision services as an essential benefit for adults. You’ll need separate dental and vision policies to help cover these costs.
What Does Health Insurance Not Cover?
Most health insurance policies do not cover:
- Abortion
- Ambulance services (except for emergencies or transfers between facilities)
- Blood and blood plasma
- Commercial weight loss products and programs
- Cosmetic procedures
- Custodial care
- Dental services
- Eyeglasses and contact lenses
- Hearing aids and hearing examinations
- Medical supplies
- Sexual enhancement (unless deemed medically necessary)
- Vision care
Types of Policies
The most common types of health insurance plans include:
- Health Maintenance Organizations (HMOs): HMOs require you to seek medical care from doctors and specialists within a specified network. An HMO will not cover any costs if you obtain medical services outside the network, except for emergencies. These plans cover hospitalization, medical care, and preventive care, and operate within a defined service area. Typically, HMOs charge a fixed copayment for covered medical services, but also require you to meet a deductible and pay coinsurance.
- Indemnity Plans: This type of policy allows you to seek medical care from the health provider of your choice. Indemnity plans cover a fixed percentage of costs, and you pay the balance. For instance, a policy might cover 80% of hospital and medical expenses and require you to pay 20%.
- Preferred Provider Organizations (PPOs): PPOs also feature a network of health providers, but allow you to seek services outside the network. However, PPOs pay a greater benefit if you seek services within the medical network. They cover hospitalization, medical services, and preventive care.
Deductibles, Coinsurance and Copays
When you use your health insurance benefits, you’ll have to pay numerous costs:
- Deductible: The deductible is a specified dollar amount you must pay before your health insurance starts covering costs. For example, if you have a $1,500 deductible, you must pay the first $1,500 in hospital or medical expenses before your insurance policy kicks in. You must reach the deductible every year before receiving benefits.
“High deductible plans exchange lower premiums for higher upfront member medical spending before coverage kicks in. Low deductible options cost more [each month] but lessen per-service charges,” said Green.
- Copayments: A copayment is a fixed amount you must pay directly to a health provider when receiving services. For instance, your plan might require you to pay $25 for doctor visits. Oftentimes, plans have different copayments for each type of service.
- Coinsurance: Coinsurance is the percentage of costs you must pay for covered services. For example, a policy might require you to pay 20% of hospitalization costs.
Note
Some plans cap the amount of benefit paid for a specific type of covered service. For instance, a policy might cover a wig for cancer patients who lose their hair but impose a coverage limit of $300.
Cost
To receive health insurance benefits, you must pay a premium, usually due monthly. For instance, an individual policy might cost $250 per month. If you purchase an individual plan outside of work, you’ll have to pay the entire premium. However, if you buy an employer-sponsored policy, your employer might cover some of the premium costs.
The cost of health insurance for you will depend on your age, where you live, the type of coverage you choose, and your deductible.
Waiting Periods
Some policies impose a waiting period: the amount of time you must wait to receive benefits after enrollment. The ACA stipulates that a waiting period cannot exceed 90 days. “Waiting periods may also apply for pre-existing condition enrollment if continuity of coverage was absent,” Green explained.
Out-of-Pocket Maximums
Health insurance policies feature an annual out-of-pocket maximum. This is the amount of money you must pay annually, after meeting your deductible, before your coverage will pay 100% of covered costs.
Dental Insurance
How Does Dental Insurance Work?
A dental plan is a separate insurance policy from health insurance. As with health insurance, a dental plan requires you to pay certain costs, such as a deductible, premiums, copayments, and coinsurance. “Dental insurance usually works by a patient paying $15-$50 per month in premiums, and then experiencing a cost savings when they receive care with an in-network dentist,” said Dr. Jordan Weber, a dentist at Burlington Dental Center.
Costs and services covered can vary depending on the insurer and plan you pick. Your employer might offer dental insurance, or you can buy coverage from insurer websites or through a government-sponsored marketplace. While the ACA offers subsidies for health insurance, none are available for dental insurance.
What Does Dental Insurance Cover?
Most dental insurance plans cover:
- Preventive care: This can include teeth cleanings, examinations, fluoride treatments, and X-rays.
- Basic restoration: Tooth extractions and fillings fall into this category.
- Major restoration: More serious restorative services can include bridges, crowns, dentures, and root canals.
“Many plans pay 100% of the expenses for preventative care. Major procedures like crowns and bridges are often covered at a lesser percent,” Dr. Weber said.
Some of the best dental insurance companies cover 100% of preventive care, 80% of basic care, and 50% of major care.
What Does Dental Insurance Not Cover?
Usually, dental plans do not cover:
- Cosmetic services, like teeth whitening or veneers
- Pre-existing conditions, such as missing teeth, that existed prior to enrolling in a dental plan
- Implants, unless deemed medically necessary
Note
Some dental insurance policies cover certain orthodontic costs, but many limit benefits to children. A few cover adult braces as well.
Types of Policies
Common dental plans include:
- HMOs: Like health insurance HMOs, dental HMOs require you to seek services within a network, and do not pay for care outside the network.
- PPOs: As with health HMOs, dental PPOs feature a network of dental providers, but allow you to seek care outside the network. While a PPO will pay some out-of-network costs, you must obtain care within the network to receive the maximum benefit. Dental PPOs account for 86% of all U.S. commercial dental insurance policies.
- Dental Indemnity Plans: This type of dental insurance enables you to seek dental care from the dentist of your choice and pays a percentage of costs. Since dentists do not work within a plan network, they’re reimbursed based on the services they provide.
- Dental Savings Plans: This type of coverage is not insurance. With a dental savings plan, participating dentists agree to offer discount prices to plan enrollees on specified services.
“If you have dental insurance, be sure to determine whether or not your preferred dentist is in-network with your insurance,” Dr. Weber said. “While it might not matter, there are many instances where your costs will be higher if your dentist is out-of-network.”
Deductibles, Coinsurance and Copays
Like health insurance policies, dental plans require you to pay deductibles, coinsurance, and copayments. The amount of copayments and the percentage of coinsurance you must pay can vary by provider and plan.
Your plan will specify the amount of coinsurance you must pay, if any. For example, a policy might require you to pay 20% of basic care costs. Likewise, the terms of the policy will specify the amount of copayment you must make for specific services. “Generally, your dentist will provide an estimate of your out-of-pocket expenses, but it is almost impossible to estimate this number accurately due to the nuance and exclusions that are in a typical insurance contract,” Dr. Weber explained.
Note
Typically, dental policies cover 100% of preventive services such as teeth cleanings, examinations, and X-rays. In such cases, preventive services do not reduce your deductible.
Cost
As with a health insurance policy, dental plans require you to pay a premium. The amount of premium will depend on the type of plan and provider you choose. Dental insurance can be affordable, with premiums starting at around $15 per month. Just make sure the policy covers enough to make up for the cost of the premiums. Take into consideration the costs of dental procedures without dental insurance, what percentage of those costs are covered by the plan, and what the coverage limit is.
Unlike health insurance, some dental insurance policies impose an annual maximum benefit. For instance, a plan might have an annual maximum of $2,000. Once the insurer has paid that much for your care, you must pay all remaining costs out of pocket.
Waiting periods
Some plans impose a waiting period for new enrollees. For example, you might have to wait six months before you can obtain restorative dental services, like a filling. However, most plans do not impose a waiting period on preventive care.
Out-of-Pocket Maximums
Unfortunately, dental plans do not feature out-of-pocket maximums. That means you’ll have to foot the bill for all services received after meeting your annual coverage maximum. There’s no cap on how much you could spend in a worst-case scenario.
Frequently Asked Questions (FAQs)
Why Is Dental Insurance Separate From Medical Insurance?
Blame history for this separation in coverage. In its infancy, dentistry was an unregulated trade. Dental insurance did not hit the market until decades after health insurance did. Insurers designed health insurance to cover unpredictable, sometimes catastrophic, medical costs, while they created dental plans to cover preventive care. Although the ACA defined 10 essential health benefits all health insurance policies must include, it only stipulates oral care benefits for minors.
Why Do Dental Professionals Ask About Your Health Insurance?
Sometimes, health problems and dental issues overlap. A tooth abscess can cause a medical problem, which your medical policy might cover.
A dentist might also inquire about your health history. For example, diabetes can increase oral glucose levels that can lead to increased bacteria in your mouth, which can cause gum disease.
What Happens If You Have No Health Insurance?
If you don’t have health insurance, you will need to pay for all your medical bills out-of-pocket. Medical providers could also deny treating you unless you pay first. Only emergency rooms are legally required to treat people without proof of insurance. In the past, the federal government charged a tax penalty for people who did not have insurance. However, the penalty no longer applies.
If you would like to buy coverage, the government-sponsored Health Insurance Marketplace sells health insurance and dental insurance policies. It offers health plans that include dental coverage and standalone dental policies. However, you cannot buy a standalone Marketplace dental policy unless you buy health insurance at the same time.
Alternatively, you can shop for a standalone dental plan on the commercial insurance market or opt for a dental savings plan.
What Is the Most Common Type of Dental Insurance?
PPOs account for 86% of the commercial dental policies sold in the United States, according to the National Association of Dental Plans.
How Do You Choose a Dentist When You Have Dental Insurance?
This will depend on the type of dental plan you pick. If you enroll in an HMO plan, you’ll have to choose a dentist from a specified network. PPO plans are more flexible, giving you the option to choose a provider from a network or outside the network. Out-of-network dentists likely would cost more though. Indemnity plans allow you to choose any dentist you prefer.
The Bottom Line
While dental insurance and health insurance companies have some design similarities (such as premiums, coinsurance, copayment, and deductible requirements), they cover two very different medical needs: overall health care versus oral care. Health insurance plans rarely include dental coverage, except for emergencies. Investing in both dental insurance and health insurance is an important part of maintaining your overall well-being.
Article Sources
Investopedia requires writers to use primary sources to support their work. These include white papers, government data, original reporting, and interviews with industry experts. We also reference original research from other reputable publishers where appropriate. You can learn more about the standards we follow in producing accurate, unbiased content in oureditorial policy.
Healthcare.gov. “What Marketplace Health Insurance Plans Cover.”
Commonwealth of Massachusetts. “Consumer Guide to Understanding Health Insurance.”
National Association of Dental Plans. “Understanding Dental Plans.”
AMA Journal of Ethics. “Overcoming Historical Separation between Oral and General Health Care.”
HealthCare.gov. “Dental Coverage in the Marketplace.”
