Why Doesn't My Insurance Pay for This? | Worthmore Dental

Understanding Dental Insurance Benefits

One of the most common questions we hear at Worthmore Dental is:

"Why doesn't my insurance pay for all of my treatment?"

Dental insurance can be confusing. Many patients expect their insurance plan to cover all dental expenses, only to discover limitations, deductibles, waiting periods, and annual maximums.

Understanding a few basic insurance terms can help you better understand your benefits and avoid surprises.

Important Dental Insurance Terms

Premium

A premium is the amount paid each month to maintain your dental insurance coverage. Depending on your plan, the premium may be paid by you, your employer, or both.

Benefits

Benefits are the dental services covered by your insurance plan. Coverage varies from plan to plan.

For example, many plans cover preventive services such as routine exams, cleanings, and x-rays at a higher percentage than major procedures.

Waiting Period

Some insurance plans require you to be enrolled for a certain amount of time before specific services become eligible for coverage.

For example, a plan may cover preventive care immediately but require a 6- to 12-month waiting period before covering crowns, dentures, or periodontal treatment.

Claim

After your dental visit, our office submits a claim to your insurance company requesting payment according to your plan benefits.

Deductible

A deductible is the amount you must pay out of pocket before your insurance begins contributing toward certain services.

Many preventive services are exempt from the deductible, while restorative and major procedures may require the deductible to be met first.

Copayment (Copay)

A copayment is a fixed amount you may be required to pay for certain services at the time of treatment.

Not all dental plans include copays.

Coinsurance

Coinsurance is the percentage of treatment costs shared between you and your insurance company.

For example:

Insurance pays 80%
Patient pays 20%

Or:

Insurance pays 50%
Patient pays 50%

The exact percentages depend on your individual plan.

Patient Responsibility

Even after insurance pays its portion, you may still be responsible for any remaining balance. This amount is often referred to as the patient's portion or out-of-pocket expense.

Annual Maximum

Most dental insurance plans have an annual maximum, which is the total amount the insurance company will pay during your benefit year.

Many plans still have annual maximums ranging from $1,000 to $2,000, although some plans offer higher limits.

Once the annual maximum has been reached, any additional treatment costs become the patient's responsibility.

PPO vs. DHMO Dental Plans

PPO (Preferred Provider Organization)

Allows you to visit any licensed dentist, although you typically receive the highest benefits when seeing an in-network provider.
Usually includes an annual deductible and annual maximum benefit.
Insurance generally pays a percentage of the treatment cost (for example, 100% for preventive care, 80% for basic services, and 50% for major services).
Greater flexibility in choosing providers and treatment options.
Out-of-pocket costs vary depending on the procedure and your plan benefits.

DHMO (Dental Health Maintenance Organization)

Requires you to select a primary care dentist within the DHMO network.
Generally has lower monthly premiums and little or no deductible.
Covered services are typically assigned fixed copayments rather than percentage-based coverage.
Referrals may be required for specialty treatment.
Out-of-network care is usually not covered.

Which Plan Is Right for You?

Both PPO and DHMO plans can help reduce dental costs. PPO plans generally offer more flexibility, while DHMO plans often provide lower monthly premiums and predictable copayments. The best choice depends on your budget, preferred dentist, and individual dental needs.

Pre-Treatment Estimate

For larger procedures, our office can often submit a pre-treatment estimate to your insurance company.

This estimate provides an approximation of:

What your insurance may cover
Your expected out-of-pocket costs
Whether limitations or waiting periods apply

Please note that a pre-treatment estimate is not a guarantee of payment, but it can help you plan financially.

Why Doesn't Insurance Cover Everything?

Dental insurance was originally designed to help offset the cost of dental care, not pay for all treatment expenses.

Many plans contain limitations such as:

Annual maximums
Waiting periods
Frequency limitations
Age restrictions
Missing tooth clauses
Exclusions for certain procedures

In many cases, treatment recommendations from our dentists are based on what is best for your oral health, not simply what your insurance chooses to cover.