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  • Writer's pictureJessica Wynn, MPH, RN

Digesting Dental Insurance Tiers: Coverage and Services Explained

Updated: Jun 25, 2023

Dental insurance typically operates on a tiered system, offering different levels of coverage based on the plan chosen. Each tier provides coverage for specific dental services, ranging from preventive care to major procedures. This article aims to provide a detailed explanation of the tiers within dental insurance, the services typically covered under each tier, and the major pros and cons associated with each level of coverage. Please see individual plans for specifics, as all plans are not exactly as follows. The following is a general overview in summation of what one may find to be true for educational purposes only.


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Tier 1: Preventive Care


The first tier of dental insurance coverage, often referred to as preventive care, focuses on maintaining oral health and preventing dental problems. Services typically covered under this tier include:


  • Routine check-ups and cleanings

  • X-rays

  • Fluoride treatments

  • Sealants

  • Basic preventive procedures


Pros:

  • Preventive care services are usually covered at a high percentage (often 80-100%).

  • Early detection and prevention of dental issues can lead to cost savings in the long run.

  • Regular check-ups can help maintain optimal oral health.


Cons:

  • Coverage for restorative or major procedures may be limited or not included in this tier.

  • Some plans may have waiting periods before certain preventive services are covered.



Tier 2: Basic Restorative Care


The second tier, known as basic restorative care, covers a broader range of dental services beyond preventive care. Services typically covered under this tier include:


  • Fillings

  • Root canals

  • Periodontal treatments (scaling and root planing)

  • Simple extractions


Pros:

  • Coverage for a wider range of services beyond preventive care.

  • Helps address common dental problems and maintain oral health.

  • Generally, higher coverage percentage compared to higher-tiered services.


Cons:

  • Coverage for more complex procedures may be limited or require higher out-of-pocket costs.

  • Certain treatments may have waiting periods or require pre-authorization.


Tier 3: Major Restorative Care


The third tier, major restorative care, offers coverage for more complex and costly dental procedures. Services typically covered under this tier include:


  • Crowns and bridges

  • Dentures

  • Oral surgery

  • Complex extractions

  • Orthodontics (in some plans)


Pros:

  • Provides coverage for more extensive dental treatments.

  • Offers financial assistance for major dental procedures that can be costly without insurance.

  • May include coverage for orthodontic treatment in certain plans.


Cons:

  • Coverage for major restorative care may be subject to waiting periods or require pre-authorization.

  • Higher out-of-pocket costs, such as deductibles and co-insurance, are common for tier 3 services.


Tier 4: Orthodontic Care (Optional) and usually age restricted to under 19yrs old


Some dental insurance plans offer an optional fourth tier dedicated solely to orthodontic care. Services typically covered under this tier include:


  • Braces

  • Retainers

  • Orthodontic consultations


Pros:

  • Provides coverage for orthodontic treatment, which can be expensive without insurance.

  • Helps individuals with misaligned teeth achieve proper alignment and enhance oral health.


Cons:

  • Orthodontic coverage may be limited to certain age groups or have waiting periods.

  • Orthodontic treatment often requires significant out-of-pocket expenses, even with insurance coverage.


Understanding the tiers within dental insurance is crucial in determining the level of coverage and services available for various dental treatments. While each tier has its own set of pros and cons, it's important to evaluate personal dental needs, cost considerations, and the significance of different dental procedures to make an informed decision when selecting a dental insurance plan.


For more information on specific plans, contact Jessica Wynn, MPH, RN, Independent Health Insurance Broker at Seven Insurance Corp, 530-512-0679. www.sevensinsurehealth.com


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