Dental insurance explained for Pittsburgh families

Dental insurance works differently from medical insurance, and the difference surprises a lot of families. Most plans are designed to make prevention nearly free and to share, not cover, the cost of bigger treatment.

Our billing coordinators answer these questions every day. Here is the plain-language version of what they explain at the front desk.

The 100-80-50 structure

Most PPO dental plans group procedures into three tiers. Understanding which tier a treatment falls into is the quickest way to estimate your share.

• Preventive, often covered at 100%: exams, cleanings, routine x-rays, fluoride for children.
• Basic, often covered at 80%: fillings, simple extractions, and sometimes root canals.
• Major, often covered at 50%: crowns, bridges, dentures and sometimes implants.

Deductibles and annual maximums

A deductible, commonly $50 per person, is what you pay before the plan starts sharing costs on basic and major work. Many plans waive it for preventive visits.

The annual maximum is the part that surprises people. Most plans stop paying after $1,000 to $2,000 in a benefit year. If you need several crowns, we can often split treatment across two benefit years so you use both maximums.

Waiting periods and frequency limits

New plans sometimes require you to wait 6 to 12 months before covering major work. Plans also limit how often they pay for things, such as two cleanings a year or one crown on the same tooth every five years. Our team checks these limits before recommending timing.

In network versus out of network

When a practice is in network, it has agreed to set fees with that insurer, which usually lowers your share. Northstar is in network with Delta Dental PPO, UPMC Dental Advantage, Cigna, MetLife, Aetna, Guardian and United Concordia. For other PPO plans, we file the claim for you and you receive out-of-network benefits.

No insurance? You still have good options

About a third of our patients do not have dental insurance. The Northstar membership includes two exams, two cleanings, all routine x-rays and 15% off most treatment for a flat yearly fee, with no deductibles, maximums or waiting periods. For larger treatment, 0% financing for 12 to 18 months is available on approved credit.

Ask for a pre-treatment estimate

For anything beyond a filling, we can send a pre-treatment estimate to your insurer so you know exactly what they will pay before you commit. It takes a couple of weeks, but it removes guesswork. You can always call our billing coordinator for a quick benefits check before your visit.

This article is general information and is not medical advice. Please see a dentist for an exam and personal recommendations.