What Dental Insurance Usually Covers

How most dental plans are built

Whether you're asking about dental insurance for braces or a routine cleaning, the answer starts with how your plan is set up. In Ontario, most people with dental insurance get it through work. Your employer chooses the plan, and an insurance company runs it. The Ontario Dental Association explains that the insurer pays back eligible claims under the terms of that contract.

The part you pay is called the co-payment or co-insurance. The ODA notes it is typically 20 to 50 per cent of the claim. Every plan is different, so two coworkers in different job groups can have very different coverage.

Common coverage groups

Plans sort services into groups. The names vary, but a common pattern looks like this:

• Preventive and diagnostic: exams, cleanings, X-rays, fluoride and sealants, often paid at the highest level.
• Basic or restorative: fillings, extractions, and often root canals and gum treatment.
• Major: crowns, bridges and dentures, and implants if the plan includes them, often paid at a lower level or after a waiting period.
• Orthodontic: braces and clear aligners, included in only some plans.

Dental insurance for braces and aligners

Orthodontic coverage is the benefit people most often assume they have and don't. Many plans leave it out. Those that include it may limit it to children under a set age, or set a separate lifetime amount for orthodontics.

Dental insurance for Invisalign and other clear aligners follows the same orthodontic rules. Some plans pay for aligners the same way as braces, while others may pay only what braces would have cost. Before you start, ask the dental office to send a predetermination with the full treatment plan. The reply shows what the plan expects to pay and how payments may be spread over the treatment.

Root canals and the crown that follows

Dental insurance for root canal treatment usually falls under basic or restorative services, though some plans class it as major. That difference changes how much you get back.

Keep in mind that a back tooth often needs a crown after a root canal. The crown is a separate claim and is usually treated as a major service, so the two parts of the same repair may be covered at different levels.

Wisdom teeth and other oral surgery

Dental insurance for wisdom teeth removal is usually handled as oral surgery. The details matter. Removing an impacted tooth, sedation and the X-rays taken beforehand are each billed under their own codes, and a plan may treat each one differently. A predetermination helps you see the full picture before surgery.

OHIP doesn't cover routine dental care. The ODA notes that some dental surgery done in hospital may be covered, and that medically necessary tooth removal may be covered with prior approval.

Limits that affect what you get back

Even covered services come with limits. Look for these in your booklet:

• Annual maximum: the most the plan will pay in a year
• Deductible: an amount you pay before the plan starts paying
• Frequency limits: how often exams, cleanings or X-rays are paid for
• Fee guide year: many plans base payments on an Ontario Dental Association fee guide, sometimes from a past year
• Waiting periods for major or orthodontic services on a new plan
• Alternate benefit rules, where the plan pays for a lower-cost option

Your treatment plan is not your dental plan

The ODA makes a point worth remembering: treatment options are set by your needs, not by your coverage. Your plan decides what it will pay back. You and your dentist decide what care makes sense. The Canadian Dental Association also cautions against basing your dental visits on what your plan covers.

A clear estimate shows both sides, so you can plan the timing and your share.

Checking your coverage in Aurora

If you're in Aurora or nearby, our office sends claims straight to every insurance plan, so you don't have to file them yourself. For larger treatment, we can ask your insurer for a predetermination first. Our insurance and payment guide explains how billing, estimates and payment work at our clinic.

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