Why Dental Plans Don’t Always Pay What You Think They Should

Have you ever bought a dental plan because you thought it would cover a crown or a root canal completely, only to find out that it did not pay nearly as much as you thought it would? This is one of the most prevalent problems that seniors and their families have while trying to figure out dental coverage. If you know how affordable dental insurance works, where it doesn’t, and how it compares to paying for things yourself, you will not have any unexpected expenses. Let us look at the most important things you need to think about while deciding between dental insurance vs out-of-pocket costs.

In-Network vs. Accepting Insurance of Dental Plans

One of the biggest misunderstandings in dental insurance comes down to two phrases: in-network and accepting insurance.

• In-network dentists have signed agreements with the insurance company to provide services at pre-set, discounted prices. For example, if a crown costs $500 in-network and your plan pays 80%, you’ll pay only $100 out of pocket.
• Dentists who accept insurance but are not in-network may charge significantly more. If that same crown costs $900 out-of-network, your insurance will still only cover what it would have paid in-network ($400). You’re left with a much larger bill. In this case, $500.

This is why it is important to check whether your dentist is in your network. If you take insurance, you may end up paying a lot more out of pocket.

Waiting Periods for Major Dental Services

Another important factor in comparing dental insurance vs out-of-pocket costs is the waiting period. Most plans impose a 12-month waiting period for major services such as:

• Crowns
• Root canals
• Dentures
• Implants
• Oral surgery

This rule prevents people from buying a plan only when they need expensive work done, using it, and then dropping it. However, some insurers offer dental insurance with no waiting period, especially if you are replacing an existing dental plan.

Tip to consider: 

Always ask about waiting periods before enrolling. If you need major dental work immediately, a standard standalone dental plan may not be the right choice.

Annual Spending Limits

Unlike health insurance, most plans have annual maximums, typically between $1,000 and $2,000. Once you reach that limit, you pay out-of-pocket for all remaining dental expenses for the year.

Some plans offer higher allowances ($3,000–$5,000), and a few may have no annual limit, but these are rare. Certain plans also increase coverage after your first year, rewarding long-term policyholders with higher yearly maximums.

This is a major consideration in inexpensive dental plans. For someone with minimal dental needs, paying cash may be cheaper than paying premiums. For those needing crowns, implants, or dentures, insurance could still save thousands, as long as the annual limit covers enough of the expense.

Dental Coverage in the Marketplace

If you are shopping through the Health Insurance Marketplace, you can access dental benefits in two ways:

Health plans with dental coverage

• The premium covers both health and dental.
• Easier to manage, but may offer limited dental benefits.

Separate dental plans

• A standalone dental plan requires a separate premium in addition to your health plan premium.
• Available only if you’re also buying a health plan through the Marketplace.

Marketplace dental plans are categorized as:

• High coverage: higher premiums, lower copays, and deductibles
• Low coverage: lower premiums, but higher out-of-pocket costs when receiving care

For children (18 and under): dental coverage is considered an essential health benefit, meaning it must be available (though parents don’t have to buy it).

For adults: dental coverage is optional; insurers don’t have to offer it.

Dental Insurance Through Medicare Advantage

For seniors, Medicare does not cover routine dental services. However, many Medicare Advantage (Part C) plans now include dental benefits. These often cover:

• Exams, cleanings, and X-rays
• Fillings and extractions
• Some coverage for dentures, root canals, or crowns

The good news: Medicare Advantage dental benefits often don’t have waiting periods. The catch? These plans also usually have annual limits, just like standalone dental insurance.

Tips Before Buying a Dental Plan

To make the best decision between inexpensive dental plans, keep these tips in mind:

• Confirm if your dentist is in-network. Never rely on us accepting insurance.”
• Ask about waiting periods. Especially for crowns, root canals, and implants.
• Know your annual maximum. Calculate whether it will realistically cover your needs.
• Compare Marketplace vs standalone vs Medicare Advantage. Each has different rules, benefits, and costs.

FAQs on Dental Insurance vs Out-of-Pocket Costs

Is dental insurance worth it compared to paying out-of-pocket?

It depends on your dental needs. For regular checkups and occasional fillings, out-of-pocket may be cheaper. For major procedures, insurance can reduce costs but only if your dentist is in-network and your plan’s annual maximum is sufficient.

Why do dentists say they accept insurance if they’re not in-network?

Because they will bill your insurer, but they have not agreed to discounted rates. This often leaves patients with much higher bills than expected.

What’s the biggest limitation of dental insurance?

Annual maximus. Once the cap is reached (often $1,000–$2,000), you are responsible for all remaining costs.

Does Medicare cover dental?

Original Medicare does not cover routine dental. However, many Medicare Advantage plans offer dental benefits, sometimes without waiting periods.

Final Thoughts

When deciding between dental insurance vs out-of-pocket costs, you should think about your dental wellness, whether your dentist is in-network, and how much care you think you will need. Some people find that paying cash for infrequent cleanings is cheaper than paying for insurance. For certain people, particularly those who require crowns, implants, or dentures, dental insurance (or Medicare Advantage dental coverage) might save them thousands of dollars in unexpected costs. Make the smart choice for your dental care and your wallet. Reach out to LMS Insurance Group for personalized guidance today.