How dental insurance is structured (the 100/80/50 rule)
Most dental PPO plans follow the same basic pattern, regardless of carrier:
- 100% coverage for preventive care — cleanings, exams, X-rays. Usually two visits per year. Deductible doesn't apply.
- 80% coverage for basic restorative — fillings, simple extractions. After deductible.
- 50% coverage for major restorative — crowns, bridges, dentures, root canals. After deductible.
Some plans also cover orthodontics and implants at varying percentages. Most have a separate lifetime maximum for orthodontics ($1,000–$2,500).
The annual maximum trap
Here's the part that surprises everyone: most dental plans have an annual maximum of $1,000–$2,000 per person. Once you've received that much in benefits during a calendar year, your insurance pays nothing else until January 1.
For context: a single crown can use $700–$900 of your benefits. Two crowns in a year and you've hit the cap. Need a root canal and a crown on the same tooth? You're paying out of pocket for half of it.
This is wildly different from medical insurance, where the deductible is usually the only meaningful out-of-pocket exposure. Dental insurance is more like a coupon — it helps, but it caps fast.
How the deductible works
Most dental plans have a $50–$100 annual deductible — the amount you pay out of pocket before insurance kicks in. Preventive visits usually don't apply to the deductible (most plans cover them at 100% even before you've met it).
Family plans typically have a $150–$300 family deductible — once your family combined hits that number, the deductible is met for everyone.
What's typically NOT covered
- Cosmetic dentistry — veneers, whitening, cosmetic bonding. These are considered elective.
- Implants on most plans — though some premium plans cover them at 25–50%.
- Pre-existing conditions — many plans have a "missing tooth clause" that excludes paying for a tooth that was already missing when you signed up. This is the rule that keeps people from buying insurance, getting an implant, then dropping the plan.
- Adult orthodontics — covered on many plans but with a separate lifetime cap.
- Treatment exceeding the annual maximum.
The "in-network" vs "out-of-network" question
PPO plans contract with a network of dentists who agree to accept reduced fees. When you see an in-network dentist, your costs are lower (the dentist takes the contracted rate). When you see an out-of-network dentist, your insurance still pays — but at a lower percentage of the dentist's actual fee.
For preventive care (cleanings/exams), it usually makes very little difference. For larger procedures (crowns, root canals), in-network can save you 20–30%.
That said: good dentists are sometimes worth the extra cost. If a dentist's reputation, technology, and approach matter to you, in-network shouldn't be your only filter. We accept most PPO plans regardless of network status, and bill insurance directly so you don't have to deal with reimbursement.
If you don't have dental insurance
Three options worth considering:
- Buy individual coverage. Plans through Delta Dental, Cigna, or Colorado-specific carriers run $25–$60/month. Math out: if you only need 2 cleanings a year, individual insurance often loses money compared to paying out of pocket. If you have ongoing restorative needs, it can be worth it.
- In-house dental savings plans. Most practices (including ours) offer in-house plans that provide reduced fees on all services for an annual membership. Often saves more than buying individual insurance, with no maximums.
- CareCredit or other financing. Pay for treatment over 6–24 months, often at 0% interest for qualifying patients.
Marketplace and Medicare considerations
If you're shopping for individual coverage on the Colorado state marketplace (Connect for Health Colorado), dental insurance is sold separately from medical insurance. Some health plans bundle pediatric dental, but adult dental is almost always a separate purchase.
Original Medicare does NOT cover routine dental care. Medicare Advantage plans sometimes include limited dental benefits — but coverage is usually capped low. Many Medicare-age patients find that paying out of pocket or using an in-house savings plan makes more financial sense than Medicare Advantage dental.