Do you regularly go to the dentist for check-ups, or do you find yourself feeling guilty about spending out of pocket? Often, we forget (or choose not to remember) that oral hygiene is important to our overall well-being. Left unattended, dental problems could lead to more serious ones in other areas of our body.
However, a recent study shows that 1 in 5 Canadians choose to skip regular visits to the dentist because of financial barriers. With the COVID-19 crisis battering the economy, it’s not hard to see why. The study also suggests that dental insurance for everybody might convince people to actively participate in taking better care of their teeth, regardless of income or economic stature.
Are you thinking of getting dental insurance for you and your loved ones? Here’s what you need to know about dental insurance in Ontario:
Dental Insurance Coverage and Benefits
Paying out of pocket for dental services can be costly. Dental insurance is a way to get the services you need at an affordable price. When you get a policy from a private insurance company, you are able to enjoy a range of dental services, known as benefits, depending on what’s covered in your policy. Dental insurance coverage can be categorized into:
- Basic Services (e.g. dental cleanings, fillings, extractions, and other minor or common dental work)
- Major Restorative Services (e.g. dentures, crowns, bridges and other major dental work)
- Orthodontic Services (e.g. braces, aligners, and other correction services)
When you buy a policy, you are entering into a contract between you and the insurance company. In exchange for the benefits under your policy that the insurance company pays for, you have to pay a yearly or monthly fee called a premium. Here’s what to expect when you buy dental insurance in Canada:
- Since most policies do not cover 100% of your expenses, you may have to pay a deductible. This is the part of the medical expense you must pay at the beginning of each year before any payment is made by your insurance company. Depending on your policy, you may have family deductibles (e.g. the first $75 in eligible expenses for any two covered family members at the beginning of each year) or per service deductibles (e.g. $5 per drug prescription).
- In addition to the deductible, your insurance plan may also have a co-insurance or co-payment feature. This means that you have to pay a percentage (around 10% or more) of the actual expenses incurred on top of your deductible, depending on the type of dental service required. This amount will not be reimbursed by your insurance provider.
- You will be given maximums—either a dollar or percentage limit—on the number of benefits you can receive under your coverage. For example, you may only be allowed 2 dental check-ups or cleanings per year.
Deductibles, co-insurance, and maximums all have a say on how much you have to pay under your policy. To reduce costs, coordinate with your spouse regarding your benefits if they have health or dental insurance. Make sure to read your policy carefully so you can manage your expectations on the expenses covered, as well as which of your policies will pay first.
Cost of Dental Insurance Plans in Ontario
The average Canadian household spends $378.60 on dental services. Dental insurance prices will vary depending on your choice of coverage, as well as other factors that the provider needs to consider. This includes your age, dental records, illness history, as well as smoking and drinking habits, and other issues that can possibly affect your dental health. Additionally, the cost will also depend on which version of the Ontario Dental Association (ODA) Suggested Fee Guide is used by the insurance company.
There are insurance companies that offer dental care under their health insurance plans and there are also others that offer dental insurance separately. You can acquire supplementary health and dental insurance via group insurance and individual insurance, which we’ll talk more about below.
Types of Insurance
Group and individual insurance offer different coverage. To choose what’s right for you and/or your family, here’s what you should know:
- Group Insurance
This covers the members of a specific group (e.g. employees of a company) and the members’ eligible dependents. Your employer pays the premium as part of your employee benefits package. If you acquire this through a professional or alumni association, you will have to pay the premiums yourself.
Under group insurance, all individuals receive the same benefits, including dental care. Some group insurance plans are flexible and allow members to pick and choose the benefits that meet their needs and to add or change benefits as their family situation changes. While eligibility for group insurance varies among providers, there a few common features:
- You may have to be employed by the company for a certain amount of time (e.g 3 or 6 months) before you receive any insurance benefits.
- Part-time or contractual staff are usually not included. Ask your employer if you are eligible and how to qualify for inclusion.
- Besides yourself, the insurance plan also covers your spouse and children under 18. Children over 18 can still be included if they are full-time students or disabled. Check with your provider for full eligibility requirements.
- Your coverage ends upon leaving the job or the association. However, if you were laid off or downsized, your benefits may continue for a few weeks. In some cases, you may be able to get replacement coverage if you apply within a certain time period.
- Individual Insurance
This is best for those who don’t have health or dental insurance through a group plan, such as self-employed individuals. Individual policies are relatively more expensive than group policies since they can be customized to fit your needs. This includes specific dental services and applications such as orthodontics and braces, and getting a dental insurance policy with no waiting period requirement.
Most individual insurance plans, whether health or dental, have specific provisions regarding pre-existing conditions. These are injuries or illnesses that you had before you applied for the insurance coverage. Most plans exclude expenses incurred as a result of these conditions.
Dental Care Under the Ontario Health Insurance Plan
The Canadian government provides basic health care to residents who meet certain eligibility requirements and the Ontario Health Insurance Plan (OHIP) is what you get here in Ontario. Once approved for OHIP, you get an Ontario health card which enables you to receive medical attention at a doctor, clinic, hospital, or emergency room at NO COST to you.
OHIP pays for most basic and emergency health care services, but it does not cover basic dental care services. What it covers, though, is in-hospital dental surgeries such as fracture repair, tumour removal, and reconstructive surgeries. You may also qualify for medically necessary tooth removal, which should be approved by OHIP prior to the procedure.
What If I Can’t Afford Dental Insurance?
The Ontario government sponsors 4 dental programs aimed to provide free dental care to seniors, kids, low-income earners, and PWDs who otherwise have difficulties acquiring private dental insurance.
Before getting the benefits from any of these programs, an application must be filed via mail or online. You are required to have a guarantor (e.g. your doctor, dentist, or any practicing member in good standing with a provincial regulatory body) apply on your behalf if you have no Social Insurance Number (SIN) or have not filed taxes in the previous year.
1.Ontario Seniors Dental Care Program (OSDCP)
Low-income seniors in Ontario can enjoy free routine dental care under the OSDCP. To qualify, you must:
- be 65 years of age or older
- be a resident of Ontario
- meet the following income requirements:
- an annual net income of $19,300 or less for a single senior
- a combined annual net income of $32,300 or less for a couple
- have no other form of dental benefits, including private insurance or dental coverage under another government program such as Ontario Works, Ontario Disability Support Program, or Non-Insured Health Benefits
Once enrolled, you are able to enjoy the following dental services for FREE:
- Preventive services (e.g., cleanings)
- Restorative services to repair broken teeth and cavities
- Oral surgery services to remove teeth or abnormal tissue
- Endodontic services (root canals) to treat infections and pain
- Periodontal services to treat gum conditions and diseases
Prosthodontic services, including dentures, are also covered to a certain extent under the OSDCP. You are encouraged to talk to your local public health unit on this matter.
The coverage period of the OSDCP is up to 1 year. However, the coverage will end on July 31st, regardless of when you enrolled in the program. Your eligibility will be automatically verified to confirm your enrollment for the next benefit period. You will also be notified by mail if you are still eligible to participate or how to re-apply to the program.
2.Healthy Smiles Ontario (HSO)
HSO offers free dental care for kids and youth 17 years old and younger in low-income families. The coverage includes preventive and early treatment services such as checkups, cleaning, fillings, X-rays, scaling, tooth extraction, and urgent or emergency dental care. Braces, teeth whitening, and other cosmetic dental applications are not covered by the program.
Children who receive assistance under Temporary Care Assistance or Assistance for Children with Severe Disabilities, or whose family receives assistance from Ontario Works and Ontario Disability Support are automatically enrolled into HSO. Ontario Works recipients living in a First Nations community are required to enrol their children to HSO, as they are not included in the automatic enrollment.
Income eligibility requirements vary depending on the number of children dependents in your household. Once your child is enrolled, they will be covered up to 1 benefit year, beginning on August 1st of the current year up to July 31st of the following year. However, those enrolled for emergency or essential care are covered for 12 months within the date of enrolment.
HSO has an age limit of 18 years old, so if your child turns 18 on the benefit year, they are no longer eligible. Re-enrollment must be done after the coverage period expires.
3.Ontario Disability Support Program (ODSP)
ODSP offers free dental care for adults that have a substantial physical or mental disability. Recipients of the ODSP, including their spouses and children, are able to get coverage for basic dental services. Additional specialized services may also be included if your disability, prescribed medications, or prescribed treatment affects your oral health. To enjoy ODSP’s dental benefits, make sure your dentist or dental hygienist is participating in the Ministry of Children, Community and Social Services Dental Care Plan.
4.Ontario Works (OW)
OW offers free dental care for low-income adults or adults that live in poverty. Like ODSP, basic free dental care under OW is discretionary, and the children of parents receiving free dental care under OW will be automatically enrolled in HSO. You might be eligible for Ontario Works if you:
- need help with your living expenses (i.e. you do not have enough money to cover your immediate family’s living expenses)
- are 16 or older
- live in Ontario (not a visitor or a tourist)
If you are eligible for ODSP or OW, click here to apply.
Should I Get Dental Insurance Now?
If you’re second-guessing getting dental insurance during a pandemic, we understand—you can surely use the money for other things. However, if you really think about it, here’s a list of dental insurance pros and cons to help you make the decision:
Pros of Dental Insurance
- You have full coverage for preventive care. You can now book your yearly dental exams and cleanings, diagnostic X-rays, and other preventive services on a routine basis. Most dental problems are preventable and having preventive services under your dental insurance policy gives you a better shot at healthier teeth.
- You can stay on top of dental problems before they become worse. Dental problems will pop up from time to time. Cavities or braces? Your dental insurance will be there to pay part of the cost so you don’t have to bear the brunt of it all!
- You can explore your options. With dental insurance, you can focus on the best course of action to take for your teeth without thinking too much about the total cost. For example, you can go for a root canal and crown instead of tooth removal; or you can get a dental implant if you choose to have your tooth extracted.
- More treatments are now included. In the past, dental implants weren’t automatically covered under insurance policies. However, more insurance providers are including them, mostly because implants last for life.
Cons of Dental Insurance
- Not all treatments are covered. Some insurance policies don’t cover cosmetic treatments, dental sealants, fluoride applications, or extra cleanings each year.
- Your maximums might limit what you get. Your dental benefits will wear out but they will reset every January 1st, or on the date set on your policy. If you need multiple fillings or crowns, your policy might not be able to cover all of them because of your dollar or percentage limits. You’ll have to decide which tooth to file a claim on this year, and whether or not the others can wait.
- Some plans require pre-approval. Before getting certain treatments, your dentist has to send in the chart, X-rays, and other supporting information to your insurance provider. This can take a few weeks or more and does not bode well for dental issues that require immediate care.
- You have to pay the deductible first. Depending on the cost of your plan’s deductible, you might still feel like you’re paying for a specific treatment entirely out of pocket.
Start Taking Care of Your Oral Health Today!
While you might want to hold out on getting dental insurance, remember that your oral health impacts your overall well-being. Make sure to take good care of your teeth, whether you’re insured or not.
Our family-friendly team of dentists and hygienists here at Dr. Urszula Barrios makes sure to give you the utmost comfort during your visits to our clinic. Call us via 519-767-6453 to book an appointment now.