Dental insurance is simpler than it looks once you know a few terms. Most plans pay a large share of preventive care, a smaller share of fillings, and about half of major work, up to a yearly limit called the annual maximum. The type of plan you have (PPO, HMO or a discount plan) decides which dentists you can see and how much you pay. This guide explains the basics so you can read your plan with confidence.
PPO vs. HMO vs. Discount Plans
Most dental coverage falls into one of three types. Knowing which one you have is the first step.
| Plan type | How it works | Choosing a dentist |
|---|---|---|
| PPO (preferred provider organization) | The plan pays a percentage of each service, up to an annual maximum. You pay the rest. | Any dentist. You usually pay less with an in-network dentist. |
| HMO (sometimes called DHMO) | Lower monthly cost and set copays for each service, often with no annual maximum. | You must use a dentist assigned to or listed in the plan's network. |
| Discount plan | Not insurance. You pay a yearly fee and get reduced prices at participating dentists. | Only dentists who take that discount plan. |
PPO plans are the most common type offered through employers. They cost a bit more each month but give you more freedom to choose your dentist.
Key Dental Insurance Terms
These are the words you'll see most on your benefits summary and on the explanation of benefits your plan mails after each visit:
| Term | What it means |
|---|---|
| Premium | What you (or your employer) pay each month to keep the plan, whether or not you see a dentist. |
| Deductible | The amount you pay yourself each year before the plan starts paying for certain services. Many plans waive it for cleanings. |
| Coinsurance | Your share of the cost after the deductible, shown as a percentage. If the plan pays 80%, your coinsurance is 20%. |
| Annual maximum | The most the plan will pay for your care in one plan year, usually around $1,000 to $2,000. |
| Waiting period | Time you must be on a new plan before certain services are covered. Often applies to major work like crowns. |
| Frequency limits | How often a service is covered, such as two cleanings a year or bitewing X-rays once a year. |
| In-network vs. out-of-network | In-network dentists have agreed to the plan's set fees, so you usually pay less. Out-of-network care may cost more or not be covered. |
| Pre-treatment estimate | A request your dentist sends to the plan before treatment to find out what it will pay. Also called a predetermination. |
Not Sure What Your Plan Covers? Call (916) 929-3737 with your insurance information and we'll check your benefits before your visit.
The 100-80-50 Coverage Pattern
Many PPO plans group care into three levels and pay a different share for each. Exact percentages vary, but this is a common pattern:
- Preventive care, about 80% to 100%: exams, cleanings and routine X-rays.
- Basic care, about 80%: fillings and other simple repairs.
- Major care, about 50%: crowns, bridges, dentures and implants.
All of this counts toward your annual maximum. If you need a lot of major work in one year, you may reach the maximum quickly, and you pay the rest. Plans also differ on what goes in each group, so check your own summary of benefits.
Most plans reset on January 1, and unused benefits usually don't carry over. See how to use your benefits before they reset.
How Insurance Works at Our Sacramento Office
Fulton Family Dental is in-network with all Delta Dental plans and accepts virtually every PPO plan. We do not take HMO plans or Denti-Cal.
We handle the paperwork for you. Before your visit we verify your benefits, we file your claims, and we give you a written estimate before treatment so you know your share ahead of time. You can find more details on our insurance page.
No Dental Insurance? You Still Have Options
Many people don't have dental coverage, and that is no reason to skip care. Preventive visits are the least expensive care you can get, and they help you avoid bigger bills later. For a sense of typical prices, see how much a dental cleaning costs in Sacramento.
For larger treatment, monthly payment plans can spread out the cost. We offer financing through Cherry and CareCredit. You can read more on our financing page, or call (916) 929-3737 and we'll talk through your options.
Frequently Asked Questions
What is the difference between a dental PPO and HMO?
A PPO lets you see any dentist and pays a percentage of each service, usually up to an annual maximum. An HMO costs less each month but only covers care from dentists in its network, usually with set copays. PPOs give you more choice, while HMOs give you more predictable costs.
Does dental insurance cover cleanings?
Most plans cover routine cleanings and exams as preventive care, often at 80% to 100%. Many plans cover two cleanings a year. Check your plan's frequency limits to see how many you get.
What happens when I reach my annual maximum?
Once your plan has paid its annual maximum, you pay for the rest of your care yourself until the plan resets, usually on January 1. If you need a lot of work, your dentist may suggest splitting treatment across two plan years when it is safe to do so.
Is a discount dental plan the same as insurance?
No. A discount plan is a membership that gives you lower prices at participating dentists. It does not pay claims, and there is no annual maximum. It can help if you don't have insurance, but only at dentists who accept it.
This article is general information, not a diagnosis or treatment plan. Every mouth is different. For advice about your own teeth, please schedule a visit or call (916) 929-3737.