Oral health is clearly a priority for most Canadians, with an impressive three-quarters of the population maintaining a consistent cadence of dental visits throughout the year. However, as with most healthcare, costs can add up. Here’s where dental insurance comes into the picture, reducing the financial burden for patients and supporting access to care.
In Canada, 64% of individuals benefit from dental insurance coverage and if you’re part of this statistic or looking to join the ranks, this article will serve as your resource to navigate the intricacies of dental insurance, making an often complex subject comprehensive and manageable.
After reading, you’ll have a solid grasp of:
- Types of dental insurance in Canada
- How does private dental insurance work in Canada?
- Can I have more than one source of dental insurance?
- What does dental insurance cover in Canada?
- How can I get dental insurance?
Understanding dental insurance in Canada is straightforward when you have the right information. In the following section, we’ll outline how to access dental coverage, ensuring you have a clear path to maintaining your dental health.
Accessing Dental Coverage in Canada
Canadians can access dental coverage through either public government programs or private insurance companies.
Public dental coverage is available from the Canadian government. These programs are designed to help people access dental healthcare; however, eligibility requirements differ by program and province.
Private dental insurance, often provided through your employer or educational institution, such as a university, requires enrollment as part of a group health insurance or employee benefit plan. The benefits department of your employer or educational institution will guide you through the available plans, affording you the opportunity to consider each before making a decision.
Understanding the financial implications of your dental plan is critical. Some of the value from your dental plan may be deemed taxable as part of your compensation. Additionally, based on your or your spouse or partner’s employer specifications, options for dual coverage or opting into a spouse or partner’s plan may be available. It is also essential to be aware that some dental insurance plans may have designated waiting period (ranging from three months for basic care to two years for restorative treatment) before you can take advantage of coverage for certain procedures. This can affect a range of services, from basic treatments such as fillings to more extensive work, like crowns. In most cases, preventative measures – including routine cleanings and x-rays – are readily available to the policyholder without the imposition of a waiting period.
Independent dental insurance, private insurance purchased directly from the provider, is an option for those who are self-employed, unemployed, or otherwise unable to access suitable coverage through an employer, a partner’s employer or an educational institution. Plans from major Canadian insurers should be carefully evaluated to determine which aligns with your needs, considering the various pricing, premiums and coverage extents.
Typically, independent dental insurance is available through Canada’s largest insurance providers, comprised of Manulife, Great West Lifeco’s Canada Life, Sun Life Financial, iA Financial Group, and Desjardins Group.
In regions across Canada, the way public and private insurance work together may differ, and some individuals may be eligible for both. It is essential to understand how these systems work in tandem and affect your coverage.
When considering public, private or independent dental insurance, consider these four questions to help you select the best option for your specific dental needs:
- Which services are covered, and how often?
- What are the coverage percentages?
- What are the potential costs (i.e., deductibles, procedures, office visits, and other services)?
- Are there coverage limits?
With a clearer understanding of dental insurance access, let’s delve into the specifics of coverage and associated costs.
Demystifying Dual Coverage
If you are wondering if you can use more than one dental insurance plan, the short answer is yes.
When you are enrolled in two plans, you have what’s called dual coverage. While this may suggest double benefits, it usually means that the secondary insurer will only pay for what the primary insurer does not cover. In some instances, you may be reimbursed up to 100% of your out-of-pocket costs for eligible treatments but it depends on the coverage limits for each plan.
This Coordination of Benefits (COB) becomes crucial, particularly when:
- You have coverage through your employer and are also listed as a dependent on a partner’s plan, or vice versa.
- Your child is covered under both parents’ plans.
Navigating which plan is primary or secondary can be complex, involving multiple scenarios and requiring a thorough understanding of how to submit claims correctly.
For example, if you’re balancing dual employment, always direct your initial claim to the insurance provider linked to your full-time job, followed by the part-time provider. However, if your hours are equally split between two jobs, prioritize the claim with the insurance provider of the job you secured first.
In scenarios where you’re juggling a retiree plan and an active employer’s plan, your current job’s plan takes precedence as the primary payer. For dependents, such as claims for children, the guiding principle is to submit to the insurer of the parent whose birthday falls earlier in the calendar year, then proceed with the other parent's plan.
Analyzing Coverage Limits
Most dental plans set an “annual maximum” or “annual benefit maximum”, which is the limit on what they will pay for restorative and major services within a given year. Understanding these limits is crucial to managing out-of-pocket expenses as some plans pay 100%; others don’t.
Think of your dental insurance as having a yearly budget of $1,000 for your treatments. Your insurer will cover their share of your dental bills up to that amount throughout the year. If your dental costs go over that $1,000 limit, you’ll need to pay the extra costs yourself. Keep in mind, not all treatments count towards this limit, so you’ll want to check your policy details to know what’s fully covered and what you might have to pay extra for.
Co-payments vs. Deductibles
Regardless of which plan you select, you will need to understand out-of-pocket costs, including co-payments and deductibles. Knowing how they work is crucial to picking a plan that aligns with your dental needs and budget.
A deductible is what you pay before your insurance starts to contribute. In Canada, a typical deductible might be $25 for an individual or $50 for a family, annually. Some plans also include a deductible for specific treatments, which must be paid before the insurance company covers their part.
On the other hand, a co-payment is your share of the cost for a dental service. Commonly, insurance might cover 80% of a basic procedure like a cleaning or a filling, leaving you with 20% to pay. For more extensive work like crowns, the cost is split evenly, with both you and your insurer paying 50%.
It is important to remember that dentists cannot ignore co-payments; they’re a set part of your plan and you’re required to pay them.
Here’s how it might look in action: Imagine you need a cleaning that costs $100. If your plan has a $25 deductible and follows an 80/20 co-pay split, you’d pay the $25 deductible outright. Then, of the remaining $75, your 20% co-payment would be $15, adding up to $40 out-of-pocket for you. Thankfully, you don’t need to pull out a calculator at the dentist’s office; they’ll handle the math, but it’s still wise to understand the process to anticipate your expenses.
Understanding Claims and How to Submit Them
Filing a dental insurance claim can be straightforward once you understand how it works. A claim is simply a detailed record of the dental services you received and the associated costs. Insurance steps in to pay their share, provided that you’ve covered any portions not included in your plan.
Let’s explore the two main paths for handling dental claims:
Direct billing: Often, your dentist’s office will send the claim right to your insurance company. This convenience means less work for you but it’s essential to understand that if the claim is denied, you’re still on the hook for the full cost. To avoid surprises, request a pre-treatment estimate from your dentist’s office to get a clearer picture of what your financial responsibility might be after insurance.
Out-of-pocket with reimbursement: Alternatively, you might pay the dentist in full and then seek reimbursement from your insurance company. In this scenario, you’ll need to submit the claim form and payment receipt to your insurer to be reimbursed.
If you’re navigating more than one dental plan, start with your primary insurance for the initial claim. After they’ve contributed their portion, you’ll receive the benefits statement, and you can then submit a secondary claim to your other plan to cover any outstanding costs. For instance, if your treatment costs $150 and your primary payor pays $100, you’ll claim the remaining $50 balance from your secondary insurer, based on your coverage with them.
It’s key to remember that even with multiple insurance plans, reimbursement will not exceed the total cost of your dental services – so you won’t receive more than the actual bill amount from all sources combined.
Breaking Down Dental Insurance Coverage in Canada
Navigating dental insurance requires understanding the different levels of coverage available, which range from basic to comprehensive options.
Basic plans generally provide for restorative and preventive treatments, such as cleanings, exams, x-rays, fillings, scalings, and extractions but they often exclude or cover only a minor portion of major treatments.
Comprehensive plans are designed to cover major restorative dental care, such as crowns, bridges, dentures, and root canals, which are crucial for maintaining dental health over the long term.
Before selecting a plan, consider your potential dental needs to help determine which plan to select.
Insurance premiums in Canada are influenced by various factors, including individual or aggregate location, age, health, and pre-existing conditions. Premiums can vary widely, from $40 to over $300 per month. While certain determinants of the premium are beyond your control, choosing a plan that aligns with your needs can prevent unnecessary expense on excessive coverage.
Now that we’ve covered the basics of dental insurance plans in Canada let’s explore some frequently asked questions.
Does dental insurance cover braces?
Orthodontic coverage, including braces, clear aligner therapy, and other corrective treatments, varies by plan. Where available, it’s usually offered on a 50/50 cost sharing basis, up to a certain amount and it’s typically a one-time benefits that doesn’t renew annually like standard dental coverage. It’s crucial to examine your plans details to understand the orthodontic benefits fully.
Does dental insurance cover implants?
Coverage for dental implants can be found in some plans, but the specifics depend on the patient’s medical necessity and the implant type. Because implant procedures are complex and may involve additional steps and supplemental procedures, such as bone grafting, which might not be covered, getting an estimate on cost and coverage is advisable before proceeding to fully understand what your financial obligation will be.
Does dental insurance cover pre-existing conditions?
A pre-existing condition is any dental condition that exists before enrolling in your new dental insurance plan. Determining what qualifies as an existing condition may be subjective by the provider; therefore, it is crucial to inquire about your condition. Coverage might still be possible, albeit with a potentially higher premium or alternative plan.
How can I make the most of my insurance?
The key to making the most of your dental insurance is understanding it well. Whether you have private insurance or access to public programs, you can further empower yourself through the following strategies:
Private dental insurance holders: Acquaint yourself with the intricacies of your policy, such as waiting periods, preferred dentists, and limits of coverage. This knowledge is key to choosing a plan that offers the best match for both your dental care requirements and your budget.
Public dental insurance beneficiaries: It’s important to understand the scope of what’s covered and how it integrates with any additional benefits you might be entitled to, so you are able to unlock the full potential of your coverage.
Independent dental insurance purchasers: Should you opt for independent coverage, you’ll still need to be mindful of the factors mentioned above.
Regardless of your coverage, adopting a routine dental visit schedule, such as every six months, is a strategic move that pays off.
The best way for patients to proactively avoid needing major dental treatments is to keep up with their routine visits. Oral health concerns caught early are often easier to treat and consequentially less expensive than if the issue remains untreated for longer.
Additionally, dental treatments are often prioritized based on necessity rather than coverage so regular visits can help your dentist schedule procedures to coincide with your plan’s coverage period, maximizing your benefits. For instance, by addressing an urgent dental issue within the current year’s coverage and postponing less critical treatments until the new coverage year can optimize your insurance benefits.
On that note, don’t lose sight of your annual maximum benefit. Staying informed about it ensures you receive all the dental care you’re entitled to without leaving unused benefits, or money, behind.
Choosing the right plan
The cornerstone of getting the most from your dental insurance is selecting a plan tailored to your needs. Ensure than the basics, such as exams, x-rays, and cleanings, are covered for everyone on the policy. Then evaluate your specific dental concerns or potential future needs, such as fillings or orthodontics, to determine the appropriate coverage level.
Being well-versed in both private and public dental is vital for effective oral health management.
Now, with a richer understanding or dental insurance, a trip to the dentist might seem a lot less daunting. With insights from this article, selecting the best dental insurance plan for you should be as smooth and comfortable as possible.
*The content provided in this article, including text, graphics, and referenced material, is intended for informational purposes only and is not a substitute for professional dental advice, diagnosis, or treatment. Always consult with your dentist or another qualified oral health professional for questions regarding your dental condition. Never disregard professional dental advice or delay seeking it based on information from this article. If you believe you have a dental emergency, contact your dentist, or seek immediate assistance from an oral healthcare professional.