What to Know About Dental Insurance & Your Treatment Plan
Dental insurance is a helpful benefit — but it doesn’t always cover everything you may need. Here are some things you should understand about how your dental plan works, so you can make informed decisions about your oral health.
Your Dental Coverage Shouldn't Dictate Your Care
When deciding on a personalized treatment plan, your dental benefits are just one piece of the puzzle. Understanding your plan helps you make sense of why your insurance may not pay for all, or even part, of your recommended treatment.
Ultimately, your dental care decisions should be made by you and your dentist — not by the limitations of your dental coverage. Together, you and your provider can choose what’s best for your health, regardless of what’s covered by your insurance.
Insurance is not a treatment plan
If you're not satisfied with the level of coverage your plan provides, consider discussing your concerns with your employer. They may be able to explore alternative plans or options in the future to better meet your needs.
X-Rays & Diagnostic Necessity
X-rays are essential for diagnosing problems— even if they’re not always covered. Most insurance plans limit how often they’ll pay for X-rays: Some allow only one set per year. Others may only cover panoramic or full-mouth X-rays every 3–5 years. However, these are necessary diagnostic tools and MANY times insurance will DENY claims without the EVIDENCE of the x-rays to support the needed treatment.
Treatment Frequency Limits
Your plan may limit how often it will cover certain treatments, even if more frequent care is recommended for your dental health. Example: Your plan might cover 2 periodontal cleanings per year, but your dentist may recommend 4. You would pay out-of-pocket for the extra visits, but you would pay our contracted rates with your insurance provider, not our standard office fees.
Treatment Plans & ADA Codes
We will provide a detailed treatment plan that includes ADA (American Dental Association) procedure codes for all recommended services.
We highly recommend calling your insurance provider to confirm:
Which procedure codes are covered?
Any limitations, exclusions, or clauses in your plan that might cause a denial for this procedure or code?
What percentage they will pay?
Your deductible and annual maximum?
Is Jensen Periodontics In or Out of Network?
This helps avoid surprises and gives you confidence in moving forward with treatment.
In-Network vs. Out-of-Network Providers
We are in-network with many insurance companies, but out-of-network with some. Being out-of-network does NOT mean your insurance won’t pay.
Coverage varies: Some plans pay the same regardless of network. Some pay less out-of-network. Some don’t cover out-of-network care at all.
It's important that you check with your insurance company to confirm whether we are in or out of network for your specific plan.
Coordination of Benefits (COB) & Non-Duplication Clause
If you have more than one dental plan, your insurance companies may coordinate payments. Most plans won’t pay more than the total cost of your care.
Some policies have a Non-Duplication of Benefits Clause, which means if one plan pays the full allowed amount, the other plan may not pay anything.
Always check with both insurance providers to understand how your benefits work together. Sometimes, neither plan will cover a service that you need.
Annual Maximum
Your annual maximum is the maximum dollar amount your dental plan will pay toward your dental care within a 12 month period. Once that limit is reached, you are responsible for paying any additional costs. It is important to know your yearly maximum—especially if you visit other dentists or specialists—so you know when you’ve reached that limit.
Deductibles and Coinsurance
Deductible:
The amount you must pay out-of-pocket before your dental plan starts covering any services. Most plans do not apply your deductible to preventative services like cleanings or exams, but some do.
Example 1:
Your bill is $100.
Your plan pays 80% of covered services, and you pay the remaining 20%.
In this scenario, your plan would pay $80 and
Total amount you would owe $20.
Example 2:
If you have a deductible (say, $50), it changes the breakdown:
Step 1: Apply your deductible
Your bill is $100, but you first subtract your $50 deductible, so the amount that’s covered is now $50.
Step 2: Apply your coinsurance
Your plan covers 80% of the remaining $50. 80% of $50 = $40 (paid by your insurance). You’re responsible for the remaining 20%, which is $10.
Step 3: Add the deductible
You still need to pay your $50 deductible in addition to the $10 coinsurance. Total amount you owe: $60 (your $50 deductible + $10 coinsurance)
Pre-Existing Conditions
Some dental plans do not cover treatment for conditions you had before your coverage started. Example: If you were missing a tooth before your plan became effective, it may not cover the cost to replace it, with a bridge or implant. Even if treatment isn't covered, it may still be important for your health. In such cases, you would be responsible for the cost.
Insurance Disclosure & Financial Responsibility
Although we strive to verify your insurance accurately, coverage isn’t guaranteed—claims can still be denied for various reasons. For instance, a previous claim may not yet be visible in your insurer’s system, even though it has already been submitted. Or, your plan may include details—like waiting periods, frequency limits, shared frequencies, or missing-tooth clauses—that aren’t accessible online, but are outlined in YOUR benefit booklet. Because many insurers restrict information to their websites, we sometimes lack full clarity when estimating benefits.
This is why it’s so important for you to ready your benefit booklet and understand your individual plan. That way, you can confidently anticipate coverage limits, familiar exclusions, and documentation requirements before receiving treatment.
We are contractually obligated to disclose all services provided during your appointment to your insurance company, ensuring that claims are processed accurately. It is ultimately your responsibility to understand your insurance plan and be financially responsible for any services not covered or paid by your insurance provider. While we are here to help guide you through the insurance process and will submit claims with all necessary attachments in a timely manner, it’s essential to be aware of your coverage limits, exclusions, and out-of-pocket costs. If a procedure or treatment is denied or only partially covered by your insurance, you will be responsible for the remaining balance.
