The deductible for dental insurance must be paid before benefits start to cover your treatment but it only applies to certain procedure codes. In other words it is an out of pocket expense that must be paid by you before your benefits kick in.
When does the deductible apply
The deductible for dental insurance will usually apply for most basic and major procedures. Essentially, it is when you "get work done" that the deductible kicks in.
Examples of basic dental procedures:
Fillings
Deep cleanings
Extractions (erupted teeth)
Root canals
Examples of major dental procedures:
Crowns
Implants
Dentures
Orthodontics
The examples above serve as a general guideline but your particular insurance plan may differ. It all depends on the type of benefits that your HR department has negotiated for you.
The best way to be sure is to either ask your dentist or inquire with your insurance directly.
When the deductible does not apply
For most dental insurances, the deductible does not apply for a lot of the preventative and diagnostic procedures.
Examples of preventative procedures:
Adult prophy (adult teeth cleaning)
Child prophy (child teeth cleaning)
Fluoride
Examples of diagnostic procedures:
Oral examinations
X-rays (bitewings, PAs, PANOs)
The above is true for most of the PPO dental insurances that we take at our office.
Exceptions: From time to time, we do see some insurances where the deductible applies for the dental cleaning and also for the x-rays. Although more commonly, it would apply for the radiographs rather than the prophy.
How to calculate the deductible
The calculation for the annual dental deductible is a straight forward subtraction.
Example 1:
Treatment needed = Dental filling ($150)
Annual deductible = $50
Your copay = $50
Example 2:
Treatment needed = 1 x-ray ($25)
Annual deductible = $50
Your copay = $25
Example 1 should be straight forward.
For example 2, you only need to pay $25 despite it being $50 because the procedure itself only costs $25. If you were to get a second x-ray, you would need to pay the full $50. Although if you get a 3rd x-ray, that 3rd one would be fully covered and would not cost you an extra dime.
How often deductibles need to be paid
The deductible for dental insurance needs to be paid every year if you receive treatment where it applies. That is why it is also called the "annual deductible."
However, it is possible to not pay it if your insurance does not apply it to preventative and diagnostic and you only need a checkup and cleaning every year. If this is your situation, you can get away with not needing to meet the limit.
Takeaway
When you go see the dentist, you may be responsible for paying the deductible if you're getting treatment where it applies. Our dentists in Long Island City recommending verifying with your dental insurance ahead of time so that there are no surprises. Our front office can also assist you with that while you're making the appointment.
