What Does My Plan Cover? | MouthHealthy - Oral Health Information from the ADA

What Does (And Doesn't) A Dental Plan Cover?

A dental benefits claim form with a pen.

Even for covered services, most dental plans share the costs of treatment with you. If you have benefits through work, the amount the plan covers is determined by how much your employer pays into the plan. If you have an individual plan, the terms will be spelled out in a contract.

Although you may be tempted to make dental care decisions based on what your plan will pay, the least expensive option is not always the healthiest option. Before committing to a plan, make sure you understand how you and your plan share costs. This is done in several ways:


A deductible is the amount you’ll have to pay for treatment before your plan coverage starts to pay. Most plans don’t require a deductible for preventive and diagnostic services.


In most cases, you will be expected to pay a percentage of the dentist’s charges or allowed benefit amount. This is called coinsurance. For example, your plan may pay 80 percent and you pay the remaining 20 percent owed to your dentist.

Annual Maximums

This is the maximum amount a plan will pay during the plan year. You pay anything over that dollar amount. For example, if your annual maximum is $1,500 and your dental expenses top $3,500, you are responsible for that additional amount. If the annual maximum of your plan is too low to meet your specific needs, you may want to ask the plan how you can get a higher annual maximum.

Also, if your plan covers braces, there is usually a separate lifetime maximum limit for the braces. 

Pre-Existing Conditions

Your dental plan may not cover conditions you had before enrolling even through you may still need treatment. You are responsible for paying these costs. For example, benefits may not be paid for replacing a tooth that was missing before the effective date of coverage.