Dental check up costs can vary greatly even with insurance. There are multiple factors that may affect your out of pocket cost despite having dental insurance. Sometimes it is fully covered while other times there are copayments.
Factors that affect cost of a dental check up with insurance:
Cost of dental check up with a PPO dental insurance
There are too many dental insurances to count but even within the same insurance carrier, the plans may vary depending on what your human resources department negotiated for benefits. Due to that, there are many factors which come into play that will affect the cost of your check up visit.
It could cost you $0 out of pocket or you may be responsible for a copayment. It all depends on the details in your specific insurance plan such as the deductible, preventative coverage, and whether you're seeing a dentist who is in-network or out of network. You would add up the amount that you'd owe in all three categories and that would be what your check up would cost.
Most PPO dental insurances have an annual deductible, which must be met before insurance benefits can be paid out. This means that in order for your insurance to cover any portion of your appointment, you must pay your provider the deductible amount. That is a legal obligation, which you signed when you on-boarded with your insurance plan.
The deductible amount may vary but most commonly we've seen it at $50 per year as shown in the example above. However, we've also seen it as low as $25 but also as high as $200.
Please note that there is an individual deductible and a family deductible. That means each member of your household has their own separate amount to pay.
On the opposite end of the spectrum, we've also encountered some plans with no deductible at all! For those fortunate enough to have this, it means that your employer must treasure you dearly.
Does the deductible always apply on the first visit?
As a matter of fact, the deductible doesn't always apply during your dental check up. You have to read the wording of your plan contract carefully.
Some plans apply the deductible to the preventative exam.
Other plans do not apply the deductible to the oral examination.
If it does not apply during the exam visit, it will most likely apply if you need some sort of dental treatment such as a cavity filling.
Preventative Coverage %
The insurance benefits are actually broken down by categories such as preventative, restorative, and etc. The dental check up falls under the preventative category and your insurance plan will cover a percentage of it.
Most commonly, we see the preventative coverage at 100% which means that the dental check up will be fully covered. This is what is show and is the case in the example above. In other words, there will be no out of pocket expense for your visit if you had this plan.
However, that is not to say that there aren't plans with coverage that are less than 100%. We do see from time to time, plans with 90% or even lower. It all depends on your plan's specific benefit breakdown. You must read through it carefully. You can always call your insurance or have your dentist verify it online through the provider's portal.
In-network vs Out of network provider
Not all dental providers are contracted with every single insurance out there to be in-network. It is simply impossible and not feasible because there are so many. Most dentists will be in-network with the more common ones but the rarer insurances, they may not be contracted with them.
It is beneficial for you as the patient to see an in-network provider because you will typically have better insurance coverage if you do. Most of the plans will break down the coverage by in-network vs out of network. Sometimes the out of net work coverage will be LOWER than the in-network one.
In the picture above, it shows an example of a difference in insurance benefits for an in-network dentist vs an out of network one. However, there are some categories that are the same regardless of network status such as the dental crowns, endodontics, periodontics, and etc. It really depends on your specific plan (we hate having to say it so many times).
This means that if you want to save some money and spend as little as possible, you should try to see a provider who is contracted to be in-network with your insurance plan. If you see someone who does not participate with your insurance, you can expect to spend more out of pocket for the copayments.
Cost of dental check up with a DHMO dental insurance
DHMO insurances are different from the PPO dental insurances. These plans usually have a fixed copay amount for each category of procedures. You would have to call your insurance directly to find out what the costs would be because each plan may vary.
We do not participate with any DHMO plans so we are unable to give you a visual example of what it would be.
You should also be aware that for a DHMO insurance plan, you're usually assigned to a specific dental office. In order for you to have coverage for your dental visit you would need to go to that specific office. If you go to a different office, your insurance will not cover the visit so please be wary of that.
Out of network cost
If you see a dental provider who is not part of the DHMO network, none of the visit would be covered. This is in contrast to a PPO plan where even if you see an out of network provider, they would still give you some coverage.
In other words, you would have to pay for the dental check up completely out of pocket as if you didn't have any dental insurance at all. Therefore, it would be in your best interest to go to an office that is in-network with your plan.
Aside from that, there is one little clause that you do have to look out for. That is even if the provider is in-network with your DHMO plan, you still have to go to your assigned office. Each plan will specifically assign you to a specific dental office. You absolutely must go to that office. If you want to switch to a different DHMO provider, you must call your insurance ahead of time so that they can switch you.
The cost of a dental check up will vary depending on what type of insurance you have. It could be fully covered and cost you nothing or there may be a copayment.
Various factors come into play which determine what the out of pocket expense would be such as the deductible, network status of the provider, and the coverage percentage.
In addition to that, you also have to take into account whether you have a PPO or DHMO insurance plan. Depending on which you have, there may be limitations or restrictions on how your dental exam will be covered.