How Dental Insurance Works in Florida
Dental insurance operates differently from medical insurance. Understanding the basics helps you maximize what you get out of your plan.
The standard structure is a yearly plan that resets each January 1st (or your specific plan year). Each year, you have:
- A premium — what you (or your employer) pays monthly for the coverage
- A deductible — typically $50–$100 per year, which you pay first before insurance kicks in
- A coinsurance schedule — what percentage insurance pays for each type of service
- An annual maximum — the most insurance will pay out in a year, typically $1,000–$2,500
There are three main types of dental plans in Florida:
PPO (Preferred Provider Organization). The most common type. You can see any licensed dentist, but you get better coverage when seeing in-network dentists. Out-of-network dentists are usually covered too, but at lower percentages. Dentist of Aventura is in-network with most major PPO plans. PPOs are flexible but cost more in premium.
HMO (Health Maintenance Organization). You must choose a specific in-network dentist, and you can only see that dentist for covered services. Lower cost but very limited choice. Dentist of Aventura does not directly contract with most HMO networks.
Indemnity (Traditional Fee-for-Service). The oldest type — you see any dentist, pay the bill, and submit for reimbursement. Higher premium, maximum flexibility. Less common today.
What’s Always Covered — Preventive Care
Preventive services are covered at 100% by virtually all PPO plans, with no deductible. These typically include:
- Two cleanings per year (every 6 months)
- Two routine exams per year
- Bitewing X-rays once or twice per year
- Panoramic or full-mouth X-rays every 3–5 years
- Fluoride treatment for children (and sometimes adults under certain plans)
- Dental sealants for children
For families, this is the highest-value part of any dental plan. Routine cleanings and exams catch problems early — when they’re small, cheap to fix, and painless to treat. Skipping preventive care almost always costs more in the long run.
Our Aventura office sees most insured patients twice a year for preventive visits. Many of our patient families have been doing this for 10+ years without significant dental work needed — because problems were caught early or prevented entirely.
What’s Partially Covered — Basic Restorative
Basic restorative services are typically covered at 80% after deductible. These include:
- White (composite) and silver (amalgam) fillings
- Simple tooth extractions
- Root canal therapy on front teeth
- Periodontal scaling for early gum disease
- Emergency exams and palliative treatment
- Sometimes nighttime mouthguards for grinding (varies by plan)
Example math for a basic restorative procedure:
- Filling costs $200
- Deductible already met for the year
- Insurance pays 80% = $160
- You pay 20% = $40
If your deductible hasn’t been met yet, you pay the deductible ($50–$100) first, and insurance covers 80% of the remainder.
Always check whether your plan considers a specific procedure “basic” or “major” — sometimes there are surprises. For example, some plans classify wisdom teeth surgical extraction as basic; others as major.
What’s Partially Covered — Major Services
Major restorative services are usually covered at 50% after deductible. These include:
- Crowns (zirconia, porcelain, gold)
- Bridges (traditional and Maryland)
- Dentures (full and partial)
- Root canal therapy on molars
- Inlays and onlays
- Implant crowns (varies by plan)
- Surgical extractions of impacted teeth
Example math for a crown:
- Crown cost $1,400 at our office
- Deductible already met
- Insurance pays 50% = $700
- You pay 50% = $700 — but wait
Annual maximum matters here. If your plan’s annual maximum is $1,500 and you’ve already used $1,000 in other services this year, insurance will only pay the remaining $500 toward this crown — leaving you to pay $900 instead of $700.
This is why timing matters. We sometimes recommend delaying a non-urgent crown until January if a patient has already used their annual maximum.
What’s Rarely Covered — Cosmetic and Implants
These categories are typically excluded or minimally covered:
Cosmetic procedures (almost never covered):
- Porcelain veneers
- Cosmetic bonding for aesthetic reasons
- Whitening (Zoom or take-home kits)
- Cosmetic gum reshaping
- Smile makeovers
The reasoning: insurance considers these “elective” treatments chosen for appearance rather than medical necessity.
Implants (variable coverage):
- Older plans: zero coverage on implants
- Newer plans: increasingly covering 30–50% of implant placement and the implant crown
- Coverage may be applied to extraction and the crown but exclude the implant itself
- Some plans require waiting periods (12 months from enrollment) for implant benefits
Orthodontics (variable coverage):
- Most plans cover children’s orthodontics at 50% with a separate lifetime maximum ($1,500–$2,500)
- Adult orthodontics is less commonly covered
- Invisalign and traditional braces are usually covered equally
Always read your specific plan booklet for what’s covered. Generalizations help, but plan details vary significantly.
Major Insurance Plans Accepted at Dentist of Aventura
We are in-network or accept out-of-network coverage from most major PPO insurance carriers active in Florida:
- Cigna Dental PPO
- Delta Dental PPO and Premier
- MetLife PPO
- Aetna PPO
- Guardian Dental PPO
- United Concordia
- Humana PPO
- Florida Blue / BlueCross BlueShield PPO
- Ameritas
- Principal
- Lincoln Financial
- Sun Life Financial
If your plan isn’t listed, call (305) 339-5701 and we’ll check. Many “out-of-network” PPO plans still pay 80–100% of in-network rates if our office accepts the plan’s fee schedule.
For HMO plans (Cigna DHMO, Aetna DMO, Humana DHMO, etc.), we do not directly contract — but we can still treat HMO patients on a fee-for-service basis.
Our front-desk team verifies coverage before your first visit. You’ll receive a written estimate of what insurance pays and what you owe out-of-pocket — no surprises at checkout.
How To Use Your Benefits Before Year-End
One of the most overlooked aspects of dental insurance is the “use it or lose it” annual reset. Unused benefits at the end of the year do not carry over — they simply disappear on January 1st.
If it’s October, November, or December and you still have unused dental benefits, here is how to maximize them:
- Schedule any postponed preventive care. If you’ve missed a cleaning or an exam this year, book it before December 31st. Preventive care is covered at 100% — there’s no reason to skip it.
- Address any pending recommendations. If we’ve recommended a filling, crown, or other treatment that you haven’t completed, this is the time. Insurance pays its share now; January starts a new annual maximum.
- Split large treatments across two calendar years. For expensive procedures (crowns, implants, multiple fillings), we can sometimes do part of the work in December and part in January. This uses two years of annual maximums, often saving $1,000+ in out-of-pocket cost.
- Use your FSA before it expires. Flexible Spending Account funds typically expire December 31st (some plans have a 2.5-month grace period). Dental work qualifies as eligible expense — schedule treatment to use up your FSA before it disappears.
Our front desk team can help you plan this. Call (305) 339-5701 in October or November for a benefits review.
No Insurance? Financing Options
If you don’t have dental insurance, you have several options at our office:
CareCredit. The most widely-used medical financing in the US. Offers 0% APR plans for 6, 12, 18, or 24 months on amounts from $500 to $25,000+. Application takes 5 minutes online with immediate decisions. Approval rates are high for patients with reasonable credit. We accept CareCredit for all procedures.
LendingClub Patient Solutions and Sunbit. Alternative medical financing with different qualification criteria. Often approves patients who don’t qualify for CareCredit.
In-house payment plans. For established patients, we can sometimes offer monthly payment plans for major procedures — typically 3–12 monthly payments, no credit application required.
Cash-pay discounts. Some procedures have a discounted cash-pay rate compared to insurance billing rates. Ask at the front desk.
Membership / in-house savings plan. Some patients prefer a flat-fee annual membership plan that includes 2 cleanings, 1–2 exams, and a percentage discount on all other services. This is often cheaper than buying individual dental insurance for healthy patients who only need preventive care.
The HSA option. If you have a Health Savings Account through a high-deductible medical plan, you can use HSA funds for dental work — including cosmetic and implant procedures that wouldn’t be covered by dental insurance. HSA money is tax-advantaged: you save 25–37% off the procedure cost effectively.
Our /finance/ and /insurance/ pages have current details on each option.
Frequently Asked Questions
Q1. Do I really need dental insurance if I rarely go to the dentist?
For most adults, yes — but the math depends on your premium. If your employer covers most or all of the premium, having insurance is almost always worth it. If you’re paying $40–$60 per month out of pocket, the value comes down to whether you use the preventive benefits. A membership savings plan (which our office offers) is often a better deal for healthy patients with low premium budgets.
Q2. Why doesn’t my insurance cover veneers or whitening?
Insurance classifies these as cosmetic procedures — done for aesthetic improvement rather than medical necessity. Insurance only covers medically necessary treatment. The exception is when a cosmetic procedure is actually needed to restore damaged tooth structure, in which case partial coverage is sometimes available.
Q3. What is the annual maximum on dental insurance?
The annual maximum is the most insurance will pay toward your treatment in a single plan year. Typical ranges are $1,000–$2,500. Once the maximum is reached, you pay 100% of additional costs until the maximum resets the next year. This is why timing of expensive procedures matters.
Q4. Can I have two dental insurance plans at the same time?
Yes — this is called dual coverage. The ‘primary’ plan pays first; the ‘secondary’ plan can cover some or all of the remaining cost (depending on coordination of benefits rules). For families where both spouses have dental insurance through their employers, dual coverage often eliminates out-of-pocket costs on routine work entirely.
Q5. What happens if I don’t have insurance and need emergency dental care?
Call (305) 339-5701. Our emergency exam and X-ray are free for new emergency patients regardless of insurance status. We provide a written estimate before any treatment. For payment, we accept CareCredit, in-house payment plans, and cash/credit card. Don’t let lack of insurance delay urgent treatment — infections worsen quickly.
Q6. Are my insurance benefits the same in-network and out-of-network?
Usually not. In-network dentists have negotiated fee schedules that match what insurance pays — leaving smaller out-of-pocket cost for you. Out-of-network dentists charge their normal fees, and insurance pays the same percentage but based on a lower ‘allowed amount,’ often leaving you responsible for the difference. We are in-network with most major PPO plans, which keeps your costs predictable.
Q7. How do I know exactly what my plan covers?
Three ways: (1) Read your plan’s Summary of Benefits document, (2) Call your insurance carrier’s member services line, or (3) Let us verify before your visit — we have direct access to insurance benefit databases and can give you a specific breakdown of what’s covered and what you’ll owe. Call (305) 339-5701 with your insurance information.
About the author
Dr. Elaine Perez-Gutierrez, DMD is a general and surgical dentist at Dentist of Aventura, licensed in both the United States and Cuba. She holds a Doctor of Dental Medicine (DMD) degree and brings a wealth of international training in evidence-based dentistry to her practice. Her clinical focus includes advanced oral surgery and implantology — same-day extractions and implant placement, full-arch All-On-X restorations, bone augmentation, sinus lift procedures, and complex restorative cases. She also performs cosmetic and restorative work including porcelain veneers, zirconia crowns, bridges, and root canal therapy. Read her full bio here.
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