If you have delta dental PPO insurance, you’re probably curious as to what the coverage entails. Does it have full coverage for every dental procedure or is there only partial coverage?
We’ve put together this guide for delta dental ppo coverage in order to give you an idea of the estimated costs of using it. That way you’ll have an idea of what kind of out of pocket costs for your treatment.
Note: What we will talk about below will only apply to seeing an in-network dentist with delta. If you see someone who is out of network, none of the below would apply. In fact, you may even get sent a check from delta if you received care at an out of network dentist office.
We’re also just giving you ball park figures, if you wanted to know how much it would cost you exactly, just ask your dentist to send out a pre-approval. You’ll receive a letter in the mail with a breakdown of the exact costs.
Table of estimated coverage and costs
This is a table showcasing some of the most common dental procedures and their estimated coverage with delta dental. We’ve also provided what you may expect to pay based on the estimated coverage.
Of course, what your actual copay will be, will depend on your specific plan and what the contract says. What we will list below is what we typically see with our patients on average.
|Dental procedure||Estimated coverage||Estimated cost||Dental code|
|Check up||100%||$0||D0150, D0120, D0140|
|X-rays||100%||$0||D0274, D0220, D0230, D0330|
|Root canal||80%||$150||D3310, D3320, D3330|
|Full dentures||50%||$700||D5110, D5120|
|Partial dentures||50%||$600||D5213, D5214|
|Dental Implants||50%||$1500||D6010, D6057, D6065|
|Wisdom teeth removal||80%||$75||D7210, D7220, D7230, D7240|
We would like to reiterate that your exact coverage and precise cost will depend on your specific insurance plan. Every plan is unique and may have their own stipulations. It is often dependent upon your employer’s HR department and what they negotiated with delta dental.
Random samples of delta dental coverages
To prove our point that your delta dental coverage depends on your specific plan, we took a random sample from 3 of our patients. They all have delta dental but the insurance is through different employers.
In other words, their plans are different which makes their coverage different as well. What that ultimately means is that all of these patients will have differing copayments.
The example above has 60% crown coverage with delta which is above average! Their preventative for check ups and cleanings are all covered at 100%
This particular example is unique in that it has 0% dental implant coverage. Don’t be fooled by the 100% because that column stands for “patient pays” which means the patient will pay 100% of the cost!
This delta dental plan has above average coverage for fillings, root canals, deep cleanings, and wisdom teeth removal. All of those procedures are covered at 90% instead of the usual 80% which is why we say it has great coverage!
Stipulations affecting insurance coverage
Most people will simply look at the column for percentage coverage and as long as they don’t see a 0% for their procedure, they think it is okay.
However, what people fail to notice are the little stipulations and fine print which may deny you benefits and coverage. These are often denoted by an asterisk or a footnote.
Delta dental stipulations which may exclude you from coverage:
- Frequency limitations. Certain procedures are allowed X amount of times over the course of X years.
- Age limitations. Some treatments will preclude you from coverage if you’re over a certain age.
- Missing tooth clause. If you are missing a tooth prior to getting the insurance, you may not have coverage for certain procedures.
- Annual maximum benefit. Your insurance will contribute X dollar amount of benefits per year towards your dental treatment.
Similar to other dental insurances, delta dental has frequency limitations for certain procedures. What that means is you’ll receive benefits for said procedure within a certain time frame.
Example: Typically, delta will allow two dental cleanings per calendar year. You’ll get coverage for two teeth cleanings per year but if you try to get a third one, that last one will not be covered.
Procedures with frequency limitations:
- Dental check ups – cleanings, exams, x-rays
- Restorative dentistry – fillings, crowns
- Tooth extraction
- Root canals
- Dentures and partial dentures
There are age limitations for certain treatments with delta dental. If you exceed the permitted age, you will not get coverage for the procedure.
Treatment with age limitations
- Orthodontics – Invisalign or braces
Example: There is a delta dental orthodontic coverage age limit of 19 or 25. That means if you’re older than that you will not get any Invisalign benefits. However, not all plans have this age limitation so it depends on your insurance.
Missing tooth clause
A missing tooth clause in your delta dental contract will preclude you for coverage from procedures which replace missing teeth. What that means is, they will not cover missing teeth procedures if you were missing that tooth prior to getting the insurance.
Treatments to replace missing teeth:
- Dental implants
- Dental bridges
- Dentures – full or partial dentures
You will be expected to pay for the whole treatment out of pocket if you have this clause. However, if you get the tooth extracted while you’re on the insurance, you will get coverage to replace it!
Annual maximum benefit
Every delta dental plan has an annual maximum benefit which they will apply to your treatment. If you exceed this limit, you will be responsible for paying for the rest of the treatment out of pocket.
What that means is even if you have 100% coverage for all dental procedures, they will cover them but only up to the annual limit. Once you exceed it, there will be no more help from your insurance.
What determines delta dental coverage?
Every delta dental plan is different because they can be customized via negotiations. Most people get their insurance through their employer and the one who does the negotiations on your behalf is the human resources department.
Typically, your HR will negotiate a contract for a couple of different tiers of plans with delta:
- Low plan
- Basic plan
- High/premium plan
If you want more coverage, you should opt for the higher or premium plan. However, if you don’t anticipate needing any dental treatment then you can get a low plan.
The differences among the various plan tiers is their monthly premium cost. The plans with better coverage will simply cost more per month.
The rationale is simple. If you want more or better coverage, you can simply pay more for it. Every benefit is negotiable, the coverage, annual maximum benefit, deductible, limitations and practically any stipulation you can think of.
How do I find out my plan’s coverage?
The best way to figure out YOUR coverage is to give your delta dental plan’s customer service a call. Their insurance representative is very helpful and will explain to you all of your coverages.
You can ask them how much your fillings are covered or how much your crown will be. They can give you a much more accurate coverage percent. The reason is because every insurance plan is different depending on which one you purchased. You can always ADD benefits by increasing your monthly premiums.
Basically, your entire coverage is technically customizable to your preference but of course it does cost more if you increase coverage.