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Dental Insurance in Texas

Dental insurance is supplemental insurance that covers the cost of part or all dental-related services and treatments (preventive care, treatments, surgery, follow-up visits, etc.). Dental insurance differs from traditional health insurance because it can be purchased either as an add-on to a major health plan or as a stand-alone coverage

Dental insurance in Texas can be usually purchased as an add-on to a group health insurance policy (if offered), or individually - either on the health marketplace or from a private insurer not listed on the marketplace.

The Texas Department of Insurance regulates and monitors the activities of dental insurance in the state. All dental insurance providers in Texas must adhere to the governing administrative code (Ch.33, Title 25).

What is Considered Dental Insurance?

Dental insurance is an insurance plan exclusively for the coverage of the expenses arising from dental treatments of the plan’s beneficiaries. Dental insurance most times is combined with vision insurance under a single plan. Dental Insurance comes in different types, covers several areas of dental health care, and provides routine preventive and restorative dental care coverage.

Dental insurance is either bought separately or attached to a health insurance plan.

What is the Purpose of Dental Insurance?

Dental insurance aims to reduce the impact of dental care treatment on the policyholder. The high cost of dental health care makes it imperative that individuals purchase dental plans to alleviate the financial burden of some restorative dental care services. Dental Insurance provides coverage for routine dental check-ups and restorative dental treatments, thereby saving policyholders from paying out-of-pocket.

In Texas, dental insurance usually offers 100% coverage for preventive dental care services and about 50% for some restorative dental care services.

What is Dental Insurance for?

Dental Insurance is for preventive and restorative dental care coverage. Dental insurance pays part of the cost of dental care treatments, thereby reducing the policyholder’s out-of-pocket costs for the services. Dental Insurance in Texas enables residents of the state to have access to high-quality dental care without any financial strain.

What are the Types of Dental Insurance?

Dental insurance plans vary depending on the cost of the premium, charges, and maximum charges set for different dental care services. Dental insurance types in Texas include Dental Health Maintenance Organization, Preferred Provider Organization, Dental Indemnity Plan, Direct Reimbursement Plan, Point of Service Plan, Exclusive Provider Organization Plan, and Table or Scheduled Allowance Plan.

  • Dental Health Maintenance Organization (or DHMO) plan: DHMO allows policyholders a choice of an in-network dentist that serves as a primary care provider. In exchange, DHMO policyholders pay the least premium but use only in-network dentists. In-network dentists are groups of dentists assembled by the insurance provider to offer services at a lesser rate. If a policyholder on a DHMO plan uses an out-of-network dentist, they will pay the fees out-of-pocket.
  • Preferred Provider Organization (PPO) dental plan: Dental PPO plans allow policyholders to get dental care from any licensed dentist of choice, and the insurer will cover some of the cost. But, the policyholder can make a lesser out-of-pocket payment by using an in-network service provider.
  • Indemnity plan: This plan allows you to get dental care from licensed dentists of choice, but the insurer may also combine this plan with a PPO plan. The insurance company will pay a percentage of the bill depending on the type of dental procedure. The dental indemnity plan has a maximum amount to offset in the invoices for each dental care treatment; this amount is called the usual customary and reasonable (UCR) fees.
  • Direct reimbursement plan: This is an individual-funded plan that allows the policyholder to choose any dentist and pay the service cost. The policy administrator reimburses the policyholder a percentage of the cost of treatment upon presentation of the receipt of payment.
  • Point of service plan: This allows a policyholder with a managed care dental insurance plan to seek services or treatments from out-of-network service providers of choice. The downside of the point-of-service dental policy is that the reimbursement paid to the policyholder comes with reduced benefits compared to using in-service providers.
  • Exclusive Provider Organization: The exclusive provider organization dental policy requires a policyholder to use only network participating dentists. However, if the policyholder chooses a non-network dentist, the policy administrator will not reimburse the out-of-pocket spending for treatments.
  • Table or Schedule of Allowance Plan: The table or schedule allowance policy pays a fixed dollar amount for treatment irrespective of the total cost of the treatment, and the policyholder makes up the balance payment.

Do You Need Dental Insurance?

The necessity or otherwise of dental insurance depends on the state of your dental health, the type of dental treatment(s) you need, and how frequently you need to visit the dentist.

Dental Insurance is not always the best option for Texans requiring minor treatments and infrequent visits to the dentists. A prospective policyholder should add up the premium, deductibles, co-payments, and the percentage of out-of-pocket payments to determine if buying a policy is worth it when an employer is not offering dental insurance.

Prospective dental insurance buyers need to consider the following before making a decision:

  • The money budgeted
  • The number of appointments with the dentist
  • Type of treatments received.

Contact a licensed insurance agent to get advice and up-to-date dental plans before deciding what dental insurance policy to purchase.

Why Do You Need Dental Insurance?

Dental Insurance offers the advantage of helping bear the cost of expensive dental procedures for the individual and family members.

Dental insurance policy choices vary as personal reasons and needs may not be the same. Some policyholders buy to alleviate the cost of getting care and treatment when due. Also, it can cover visits to the dentist for preventive check-ups that may help avoid future health complications.

How Much Dental Insurance Do You Need?

The amount of dental insurance you need may depend on your dental condition and plans for future dental procedures. Buying a dental plan may also be for preventive dental treatment to avoid future occurrences of dental diseases.

The following factors can influence the decision on the choice of a dental insurance plan and the amount of coverage:

  • How many of the in-network dentists are close by?
  • Is the current dentist part of the network?
  • How much will it cost for visits to the dentist
  • Can appointments be scheduled at convenience?
  • Do you need coverage right away without waiting periods?
  • Do you have missing teeth and need orthodontics and dental implants?
  • Do you need a higher maximum annual benefit amount or specific coverage type?

Discuss your dental insurance needs with a Texas state-licensed insurance agent to get advice on available dental plans and how they can fit with your particular dental care needs.

What Dental Insurance Coverage Do You Need?

The type of dental insurance you need depends on the policy type, the benefits it offers, the number of people it covers, and the main purpose for which you are getting dental insurance. The benefits differ between routine and non-routine care treatments.

There are three types of insurance plans you can choose from depending on the number of beneficiaries and your employment status:

  • Individual Dental Insurance plan
  • Family Dental Insurance plan
  • Private Dental Insurance plan

The individual plan provides coverage for a single beneficiary whose name is on the policy document. In contrast, the family dental insurance plan covers family members listed in the policy document even when only one member is registered.

The family can leverage the family dental insurance plan of one of the family members where only one member is gainfully employed. A family member with a dental insurance plan can include others as beneficiaries in the policy.

Private dental insurance plans can come as a benefit from employment, or be purchased individually on the open market.

A licensed Texas health insurance agent can recommend an appropriate plan for policyholders based on individual needs. Receive dental insurance advice from a local insurance professional.

Is Dental Insurance Required by Law in Texas?

Dental insurance in Texas is not required by law.

The Affordable Care Act (ACA) mandates that dental insurance must be available to kids aged 18 years and below - as an essential health benefit (EHB). Dental Insurance for children is part of a child’s healthcare plan or a stand-alone policy. Though the federal health law mandates that dental insurance must be made available to children, you are not obligated to buy it.

For adults, dental coverage is not considered an ACA-EHB.

How Does Dental Insurance Work?

Dental Insurance in Texas is similar to other types of insurance. By paying premiums, policyholders share the cost of treatments and services with the insurance company. Some dental plans have maximum annual amounts the insurance company can pay within the year; this maximum amount paid by the insurance company is called the Annual Maximum. When the maximum has been exhausted, the policyholder pays the rest of the cost of the treatments out-of-pocket.

Texas residents usually purchase dental insurance through the employer, a Texas-licensed health insurance agent, or on the federal health insurance marketplace.

What Does Dental Insurance Cover?

Dental Insurance covers many services under routine preventive care and non-routine care. The services covered by dental insurance policies include:

  • Routine Preventive Care - Preventive services are covered by both group and individual plans, usually without a required deductible. It covers preventive services such as: professional teeth cleaning, scaling, X-rays, fluoride treatments, and exams.
  • Non-Routine treatments - Non-routine treatments include root canal work, fillings, bridges, dentures, orthodontics (for children aged 19 and below), periodontal treatments, extractions, dental implants, restorative care, and other surgeries.

What is Dental Insurance Good for?

Dental Insurance is good for paying for preventive treatments to maintain good oral health. Dental insurance is also good for helping with the costs associated with treatments for restorative dental care, dental deformities, and diseases.

If you have questions about dental insurance, it is best to speak to a state-licensed health insurance agent.

What Does Dental Insurance Typically Include?

Dental insurance typically includes coverage for both preventive and restorative dental care treatments. Dental insurance in Texas is similar to regular medical insurance policies and follows similar patterns. Insurance coverage provides policyholders the dental benefits listed in the policy document as long as they pay the premiums; it emphasizes preventive care to limit the more costly restorative treatments resulting from oral diseases.

The most important and frequently overlooked benefit of dental insurance is the Negotiated rate with the dental provider. Just by having insurance the insured already pays 10% - 35% lower price for dental services and visits, compared to what they would pay if they came in without dental coverage - even if you pay for it out of pocket.

Dental insurance policies can be grouped based on costs and coverage:

  • Class I - these are diagnostic and preventive and include examination, cleaning, and X-ray.
  • Class II - Basic services. This class provides care and procedures such as fillings and root canal work.
  • Class III - Major procedures like crowns, bridges, and dentures are under Class II services.
  • Class IV - This class is for orthodontia (braces) services.

The coverage is typically laid out in tiers. The more coverage you need, the more expensive the plan becomes. Most individual dental insurance plans in Texas

Individual cases may differ, but a licensed health insurance agent will shed more light and recommend a suitable policy for individual dental insurance needs.

Who is Covered by Dental Insurance?

Dental insurance provides coverage for individuals whose names are in the policy document.

  • The individual dental insurance plan provides coverage only for the policyholder. However, if the dental insurance plan is through an employer, the policyholder can add dependents at the initial signup for the policy.
  • The family dental insurance plan provides dental benefits for the family members listed in the policy document. The number of beneficiaries under dental insurance coverage depends on the type of plan.

What Types of Items Does Dental Insurance Cover?

Dental Insurance covers routine preventive care and non-preventive dental treatments for adults and children. Routine-preventive care coverage includes oral examinations, professional oral cleansing, mouth X-rays, fluoride, and scaling treatments.

Non-preventive treatments (or restorative) dental treatments that dental insurance usually covers are:

  • Teeth filling (amalgam and composite).
  • Teeth extraction surgeries.
  • Crowns.
  • Root canals.
  • Total (or partial) dentures treatments.
  • Treatments for soft tissues infections (periodontal).
  • Braces (orthodontics) for children and adults.

Note: Always check the exclusions page of every policy. There you can double-check if your needs are sufficiently covered, or possibly excluded. Speak to a licensed health insurance agent, to get more information about possible dental coverages near you.

Does Dental Insurance Cover Implants?

Some Texas dental insurance policies offer coverage for dental implants as part of policy benefits; these insurance plans usually come at a high premium and with higher than average deductibles.

While some Texas dental plans cover implants from the start, the majority of individually purchased dental plans on and off the health marketplace have a waiting period, before implant coverage begins. The waiting period is typically 1 to 2 years.

Does Dental Insurance Cover Crowns?

Yes, dental insurance covers crowns, up to the limits specified in the plan. Most group plan provide coverage of 50% (up to the annual maximum), while individually purchased Texas dental plans typically build up coverage over time (10% coverage during the first year, 30% - 40% the second year, and 50% from year 3-on)

Depending on the material dental crowns in Texas can cost you $500 to $3,500.

Does Dental Insurance Cover Fillings?

Yes, dental insurance covers fillings (according to the plan provisions, policy limits, and exclusions)

Does Dental Insurance Cover Root Canals?

Yes, dental insurance covers root canals, as part of both the:

  • non-preventive treatments, and
  • restorative dental treatments

Coverage is dictated by the policy and its exclusions.

What Does Dental Insurance Typically Exclude?

Dental insurance plans typically exclude cosmetic procedures such as teeth bleaching, fixing gold teeth and other accessories, and complicated oral surgeries requiring hospitalization.

Dental illnesses that exist before the policyholder buys a dental insurance plan are usually not part of the insurance coverage, at least not from the start. After a waiting period, minor pre-existing conditions may be allowed. Until the waiting period is over, policyholders are to pay for such treatments out of their pockets.

What is an Example of Dental Insurance?

Dental insurance plans come in different types, based on the policyholder:

  • Individual Dental Insurance plan
  • Family Dental Insurance plan
  • Private Dental Insurance plan

Regardless of how the Texas dental insurance plan is purchased, it functions like this:

  1. You visit the dentist’s office and provide your insurance information to the staff at the clinic.
  2. The clinic’s staff looks up your coverage in the database or contacts the dental insurance company with any clarification questions. You proceed to see the doctor for treatment.
  3. After your dental visit, the dentist submits the claim to your insurer, to get paid for the provided services.
  4. The insurer pays its share of the costs according to the purchased coverage, exclusions, and possible waiting periods.
  5. If you did not pay your portion at the time of the visit, the dental office bills you through the mail, or waits to settle the bill until you come back for the next check-up.

Some employers provide dental insurance coverage for their employees to reduce the cost of treatments and motivate employees to go for regular check-ups. Regular check-ups detect and treat dental conditions early, reducing the production time lost due to hospitalization. An individual can buy a dental policy for regular visits to the dentist for good oral health.

What is the Most Common Use of Dental Insurance?

The most common use of dental insurance is to help cover the costs for:

  • Preventative dental visits (usually 2 per year)
  • Emergency dental work (covered up the plan limits)

What is the Difference Between Dental Insurance and Health Insurance?

Dental Insurance provides coverage for care and treatment for oral conditions only. It is not part of the major health coverage, but it can be purchased as a stand-alone or supplementary coverage. On the other hand, health benefit plans provide coverage for care and treatments of most illnesses of the whole body.

Dental insurance pays only a part of the cost, while health insurance may pay the total fee of treatments. Note: This can be remedied by a supplemental dental plan:

What is the Difference Between Dental Insurance and Supplemental Dental Insurance?

Dental insurance is a supplemental type of policy. It supplements health insurance with additional coverage, which it does not provide on its own.

Supplemental dental insurance supplements a primary dental plan, covering the costs that the main plan does not cover.

Do I Need Dental Insurance if I Have Health Insurance?

You may need a dental insurance plan if you already have a health insurance policy.

Most Texas health plans (ACA and Short-Term) exclude coverage for dental treatments. A health insurance policyholder may need to get a dental insurance plan to cover the costs of dental treatments, instead of paying for them out-of-pocket.

Discuss your dental needs with a Texas-licensed insurance agent.

Who Can Get Dental Insurance?

An adult who is interested in maintaining good oral health and capable of paying a premium can get a dental insurance policy for self or family members. Employers or organizations can also buy for the staff or the public.

Consult a licensed insurance agent for more clarifications before purchasing the insurance policy.

Who Qualifies for Dental Insurance?

Any adult legal resident of Texas who can pay a premium for dental insurance coverage is qualified to get a dental insurance policy. The Medicaid and CHIP program of the Texas government provides dental coverage for Texan citizens. Also, low-income pregnant women are entitled to low-cost dental services up to two months after conception.

Who Needs Dental Insurance?

You need dental insurance if:

  • You are interested in maintaining healthy oral hygiene for self, family, or your employees. Besides the preventive basic services, dental insurance assists with covering dental care costs for major services too.
  • You need dental work done and do not want to pay for it largely out of pocket. Those costs can be pre-planned as long as the correct and timely dental coverage is purchased. By paying the annual premium the insured gets access to covered dental claims up to the annual plan limits.

For example, if the monthly plan cost is $45 and the plan’s annual (calendar year) maximum coverage is $2,000, the insured is paying $540 per year to have access to $2,000 of claims. Speak to your dentist about maximizing the use of your dental plan’s coverage.

Most importantly - you need dental insurance if you want access to lower pre-negotiated rates for dental work, even if you run out of the annual coverage. You qualify to pay lower dental care costs just for being insured - which can save 10% to 35% off the walk-in dental clinic prices. If you have used up the maximum annual limit and are now paying cash for the services provided, the participating providers (dental offices) will continue to bill you the same (lower) price that they normally bill to your insurer. Discuss your dental insurance needs with a licensed health insurance professional who is familiar with the locally offered dental coverages.

Who Should Get Dental Insurance?

You should get dental insurance if you are:

  • Looking for ways to reduce dental care bills
  • Seeking quality dental care treatment at pocket-friendly rates
  • Searching for motivation to maintain a good dental hygiene

Seek the advice of a Texas-licensed health insurance agent, who can guide you through the available dental insurance options.

What are the Benefits of Dental Insurance?

The benefit of dental insurance is to afford the policyholder a means to reduce the cost of dental care and make quality dental care treatments available.

Dental Insurance does not work the same way other insurance plans do. A homeowner or auto insurance plan will pay for repair or replacement of the house or car in the case of a valid claim, but a dental insurance policy does not do so. Dental Insurance only pays part of the cost for dental health care or treatments.

Why is Dental Insurance Good?

Dental Insurance is good because it provides access to expensive dental procedures, which are frequently expensive and not otherwise covered by any other type of insurance.

Why is Dental Insurance Bad?

Dental insurance may not be ideal if the cost of coverage exceeds the benefits it provides to the insured.

If year after year you use dental insurance coverage for the 2 annual cleanings and nothing more - check how much you have paid in. It may be more cost-effective to pay out-of-pocket for each visit.

But then again, what if you get a toothache without the proper coverage? Any dental pain can expand into an expensive problem - and that’s where dental insurance steps in.

Is Dental Insurance Worth it?

Yes, dental insurance is worth it because you know that if any work needs to be done to your teeth, you have a partner, with whom you are splitting the resulting costs.

Before buying a dental insurance policy, consult with a licensed Texas insurance agent for recommendations on policies with the most optimal benefits to fit your specific needs.

What Happens if You Don’t Have Dental Insurance?

If you do not have dental insurance, in most cases, you are paying for dental care out of your pocket at a non-negotiated rate, which can be 10% - 30% higher than the insured patients. Although, in cases of life-threatening medical emergencies in the emergency room (ER), if the patients have health insurance plans, dental bills are sent to the health insurance providers.

If you do not have dental insurance, speak with a Texas-licensed insurance agent who can recommend several affordable dental plans based on your needs.

Why is Dental Insurance Important?

Dental Insurance is important for the following reasons:

  • It pays part of the cost for dental care treatments.
  • It helps to keep good oral hygiene and prevent the occurrence of rheumatoid arthritis and some life-threatening heart problems.
  • Dental insurance plans can make a policyholder have regular appointments with the dentist and reveal early signs of illnesses that may lead to more problems.
  • Dental Insurance provides coverage for dental emergency cases and helps pay for dental surgeries or accident cases.

What Happens When Your Dental Insurance Lapses?

When there is a default (lapse) in the payment of a premium for a dental policy, the insurance company notifies the policyholder that they have a set amount of time to pay, or risk losing the coverage. This is referred to as the grace period. In Texas the grace period is 31 days.

During the grace period, the insurance company will continue to provide coverage unless there is a written letter from the policyholder seeking the termination of the policy. However, a lapse of coverage will set in if the grace period expires and the policyholder is yet to pay the premium. The policyholder loses insurance coverage and will no longer be entitled to any benefit within the remaining period the coverage is supposed to run. .

Try to avoid lapse in insurance coverage. Make sure you understand what lapsing means for your type of policy. Speak to a licensed Texas insurance agent, to find out more.