Understanding the Mysteries of Dental Benefits


All the things you want to know, and then maybe some extras you didn’t know you needed.

I will be speaking to you candidly and in a generalized manner because everything is unique to each person/situation, but I’m hoping this post will inform you for your future visits.

You will not believe how complicated this is going to get…

Here’s some information about insurance/dental benefit plans…



What is dental insurance/benefits?

My way of describing it is that it’s a coupon from a company that gives you a discount on dental treatments/procedures. This coupon allows you to get 75, 80, 90, and 100% sometimes more and sometimes less up to a certain amount off the care that you need/want. BUT, it is not the dictator of the things that you need! It is what the company is WILLING to contribute to, and in general benefits companies don’t want to LOSE money. That’s why there are limitations. At the end of the day the insurance company needs to ensure that they stay afloat, so they bank on the idea that most people utilize less than the money they bring in. 

Your dental provider recommends treatments that you require based on their professional assessment of your mouth. The recommendations are regardless of what your dental insurance covers, therefore, it MAY or MAY NOT be a covered expense. For the treatment recommendations that are not covered, it’s your choice to pay for them or not. Our job is to provide you information on your options, and then the risks and benefits of each thing. For example, your choice in every scenario is always to

  1. do nothing
  2. do x
  3. do y
  4. do a combination of x and y

There are no guarantees that things will work out in life, and the same goes for treatments in dentistry. As dental providers, we all just do our best to help you make decisions that fit your values, needs, and wants for oral health care. As a Dental Hygienist, my ultimate goal for you is that you receive knowledge to make an informed choice and understand what the potential consequences or wins are; I want you to have optimal oral health and overall wellness in a way you are comfortable with. Keep in mind, as a dental hygienist, my focus is always the prevention of disease and dental problems. A dental hygiene visit/cleaning is like a meal out at the restaurant: appies, entrees, and desserts. All make for a great meal and different parts add up to a “full meal”. In a dental cleaning, each of these parts are assigned a treatment code. There is no lump sum price for a cleaning, and when you call for quotes at a dental office you need to compare the codes that they’re quoting you for (and specify that), because otherwise you’re comparing apples and oranges, and that isn’t really a comparison/fair at all. 

You may choose to ask, “What does a cleaning cost? And what does it include?”

Other good discussion points are: “What’s the main priority? What are the risks/benefits of doing or not doing xyz? Where should I focus first? I have a limited budget, so can you please work with that? ASK MORE. TAKE OWNERSHIP of your appointment. Be informed and knowledgeable about the things you are consenting to!



Now let’s get into the nitty gritty of dental insurance/benefits…


Coverage amounts: Let’s say you have a plan with 100% coverage overall, but in the fine print, you may have some “types” of procedures covered at different amounts.

For example, Major Procedures is a category defined by your insurance, and things like crowns bridges etc. typically fall into that; often this category is covered at 50% or 60%, but it varies. Also, Basic Procedures consist of things like fillings, extractions, and dental hygiene/cleaning (which I mentioned has different parts to it). Be aware that each benefits plan is different, even when it comes to the “basic” dentistry coverage. Make sure you don’t get any treatments done without getting a pre-determination/preauthorization first, and then move forward when you know the estimated amounts as close as foreseeably possible. There is a lot to say about planning and preparedness! Then there are other categories like orthodontics, periodontics, endodontics etc., and these are all specialist/specialty categories, so often they are covered differently, or with different limitations.


Understanding MAXIMUMS in Benefits Plans

Maximums need to be “monitored”. You can have a “dollar amount” maximum, for example, personal plans are usually $700 or $750, or a group plan with a maximum of $1500, $2000, or $2500. There are also “procedure code” maximums. A benefits company may allow for a specific amount of scaling they will cover in your plan. For example, you get 4, 8, 10, or 12 units of debridement/scaling (cleaning time) per year; that means that you get 4, 8, 10, or 12 15-minute time blocks per year.  Those units can be divided up as you may need; they can be used all at once, broken up into 2 visits, or even 3 or 4 visits. BUT, if you have reached your dollar maximum or exceeded the “unit” allotment per year, then your insurance won’t pay, and you will have to pay the balance. Here is where the planning comes into play. This will help to eliminate, or at least limit, surprise dental bills.


Fee guides

This is another big thing to consider. Each province has its own fee guide produced by an Association of the treatment provider “type”. That means each provider type and each provider can have different fee price points for each type of office. So, if your dental benefits company is from a different province like BC, but you are using it in AB, then often you will be covered at the fee prices set in the province that the insurance is from (and NOT the province where you are receiving care). So, typically insurances in BC are covering less dollars, than the ones in AB, so if you had 100% coverage in BC, then it is not 100% in AB because the fees may be higher in this province. Furthermore, sometimes what happens is a person retires, and the fees their plan covers are based on the year they retired, and they don’t change. In this case, you can have 100% of the fees covered from 1999, and then you still have to pay the balance because the prices have increased!

Why is it that even with good benefits coverage, you still owe money sometimes?

As providers, we can do our best to plan, anticipate and estimate BUT, there are limitations. (And we can make even make mistakes!) We can’t guarantee that your insurance is going to work that day because there are so many parameters to consider or updates to plans that we are not aware of. As much as we try not to, we can get it wrong too. Our job is to help assist with everything, but at the end of the day, the onus is on you to know your plan and understand that you pay the balance. Now, having said that, when things go awry, and you are sent a bill/statement, then just call and work out the finances with your office; they’re usually accommodating and understanding of surprises like that because often they too are surprised!  I am surprised all the time by how much I still don’t know; that is how intricate benefits plans can be and there are SO many different types of plans out there! 


This can seriously feel like a lot of information, and it can still confuse/complicate things, so call/email me for information, and I’d be happy to clear it up as best as I can – no guarantees though!

The end of the year is approaching. For me, this means a lot of last-minute appointments are requested when people are trying to use up their benefits before the end of the year. Does your plan renew at the end of December? If so, please don’t be last minute; save me some stress and book your appointments NOW.

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