Understanding Dental Insurance: 9 Facts You Should Know

If you’ve ever felt confused or frustrated by your dental insurance plan, you’re not alone. Whether you have coverage through an employer or an individual plan, navigating dental benefits can be tricky. As healthcare providers, we understand that while dental insurance is useful for patients to receive treatment, it is also designed to be complicated and we want you to have a better understanding of how it works.

We’ve dealt with dental insurance for many years, and our goal is to help demystify dental insurance—so you can make informed decisions about your oral health and hopefully added costs in the process.

Check back for more posts to help you navigate your dental insurance and maximize your benefits. For this discussion, we’ll focus on how dental insurance applies to general dentistry, rather than specialist care.

9 Important Facts About Dental Insurance

1. Dental Insurance Isn’t Exactly Insurance

Unlike medical insurance, which helps cover large, unexpected expenses, dental insurance is more like a coupon or discount plan—it is designed to supplement or aid your care, not fully cover it. Thanks to savvy insurance marketing, many people assume their plan will pay 80% or even 100% of dental fees, but in reality, coverage often falls between 40–60% of an average dental fee.

Why? Ultimately, the amount a plan pays is determined by how much you or your employer paid for the plan. You only get back what you or your employer put in, minus the profits of the insurance company. Additionally, many plans have fee schedule allowances, annual maximums or limitations which are not always easily accessible or disclosed to the patient or even to your dentist without contacting the insurance carrier directly.

As an advocate for your oral health, your South San San Francisco dental team provides a complimentary insurance verification which gathers these important details to the best of our ability to help provide an accurate estimate of what your insurance will cover.

2. Maximum Coverage Hasn’t Kept Up With Rising Costs

Many dental plans still have an annual maximum benefit of $1,000 per person—a number that hasn’t changed since the 1960s! Meanwhile, the cost of care, materials, and technology has increased significantly. More than 50 years later, most plans still have an amount of $1,000, sometimes $1,5000. While your premiums have increased, your benefits have not. This means even basic treatments can exceed your annual coverage limit and it's important to remember that your dental insurance is never a "pay-all".

3. Many Routine Treatments Aren’t Covered, Regardless of Need

Preventive care, like cleanings and small fillings, can save you from costly treatments down the road. Yet, some insurance plans only cover deep cleanings after gum disease has progressed to bone loss. Others restrict how often a tooth can be filled—meaning you could be forced to wait even if the tooth breaks or develops new decay.

4. Insurance Companies "Down-Code" to Pay Less

Your plan may only pay for a composite (tooth-colored) filling at the rate of a silver (amalgam) filling—or refuse to cover composites on molars entirely. But most dentists no longer use amalgam, and patients prefer natural-looking fillings.

Is your insurance company looking out for your health or just their bottom line?

5. Your Dentist Charges the Same, Regardless of Insurance

Dentists don’t set different prices based on whether or not you have insurance. However, insurance companies determine what they consider "Usual, Customary, and Reasonable" (UCR) fees, which may not reflect actual costs. They also use language that can make it seem like your dentist is overcharging—when in reality, your insurance is just paying less.

6. In-Network Dentists Accept Lower Fees—With Trade-Offs

Insurance companies encourage patients to visit "preferred providers," who agree to discount their fees. While this may seem like a cost-saving measure, it can often mean dentists must see more patients in less time, use lower-cost materials, and limit services.

Many corporate-owned dental offices operate this way. If you’ve ever felt rushed or received impersonal care, this could be why.

7. PPO Plans Let You Choose Any Dentist

If you have a PPO plan, you are not required to see an in-network provider. You have the freedom to choose your own dentist, and benefits will still be paid. In fact, non-network offices may have higher UCR allowances than in-network providers!

8. Your Insurance Doesn’t Dictate Your Care—Your Dentist Does

Insurance companies don’t diagnose or treat dental conditions—your dentist does. Yet, they often deny procedures as "unnecessary" simply to save money. We believe in providing the best possible care for our patients, not letting insurance companies decide what’s needed.

9. We’re Here to Help You Navigate Your Benefits

We know dental insurance can be confusing, and we’re always happy to help you understand your coverage. Our goal is to maximize your benefits while ensuring you receive the high-quality care you deserve.

At the end of the day, your oral health is what matters most. We want you to be happy, healthy, and smiling for years to come! If you have questions about using your insurance or maximizing your benefits to get the care you need, we're just a phone call or email away.