Demystifying Dental Insurance in Ontario

Maximize Your Benefits

Dental insurance can often feel like a complicated puzzle, but understanding how it works can help you get the most out of your coverage and care. Whether you have a comprehensive plan through your employer, or a basic one purchased independently, knowing exactly what is covered, how to interpret your benefits, and how to make the most of limited coverage can help save you money and ensure you receive the care you need.

How Dental Insurance in Ontario Works  

In Ontario, dental care is not covered under the Ontario Health Insurance Plan (OHIP) for most residents. However, OHIP does cover some hospital-based dental surgeries, such as jaw reconstruction, jawbone surgery, tumour removal, and fracture repair.

Instead, dental coverage is typically provided through employer-sponsored benefits, private insurance plans, or government-funded programs for specific groups such as seniors, low-income families, and children.

Dental insurance plans operate on a reimbursement model, meaning the insurer pays for part of the treatment, and the patient covers the remaining portion. Depending on your insurance company and dental clinic, they may be able to direct bill your insurer, meaning you will only pay for the remaining portion. However, if you are not able to direct bill your insurer, you will be expected to pay for the entire cost of the treatment upfront, and then submit your receipts to your insurance company to receive reimbursement.

Coverage is usually based on a fee schedule, which determines the maximum amount an insurance provider will pay for specific procedures.

Most plans categorize treatments into the following:

• Preventative Care – Includes cleanings, exams, and X-rays (often covered at 80-100%)
• Basic Care – Includes fillings, root canals, and extractions (typically covered at 50-80%)
• Major Restorative Care – Includes crowns, bridges, dentures, and implants (coverage usually ranges from 20-50%)
• Orthodontics – Includes braces and aligners (if covered, usually has a lifetime maximum rather than an annual limit)

Understanding Your Insurance Plan

Key Terms to Know

1. Annual Maximum: The total amount your insurance will pay per year.
2. Deductible: The amount you must pay out-of-pocket before insurance starts covering the cost.
3. Co-Payment (Co-Insurance): The percentage of treatment costs you are responsible for after insurance pays its share.
4. Fee Guide: The Ontario Dental Association (ODA) publishes a guide for standardized procedure costs, which many insurance providers use to determine coverage amounts.
5. Limitations & Exclusions: Some treatments have specific rules, like frequency limits (e.g. one dental exam every 9 months).

How to Read Your Dental Insurance Policy

Your dental plan summary will outline your coverage percentages, limits and exclusions.

It’s essential to review:

• What procedures are covered under preventative, basic, and major care.
• How often you can receive cleanings, X-rays, or other treatments.
• Whether there is a waiting period before certain treatments are covered.
• If your plan allows you to see any dentist or if you must use a specific network.

If you’re unsure about any part of your policy, your dental office can often help clarify coverage details before treatment. Also, don’t hesitate to call your insurance’s customer service line to clarify anything you are unsure about. They are there to help after all.

Maximizing Your Dental Insurance Benefits

1. Schedule Regular Preventative Care Appointments

Most plans cover cleanings and checkups at 80-100%, making them a cost-effective way to prevent expensive treatments later. Staying consistent with visits can help detect issues early and reduce out-of-pocket costs in the long run.

2. Know Your Coverage Period

Many plans reset annually (often in January or July). If you have unused benefits approaching expiration, consider scheduling needed treatments before they reset. Some treatments can be strategically timed across two benefit years to maximize reimbursement.

3. Coordinate Benefits if You Have Dual Coverage

If you and your spouse both have dental insurance, you may be able to coordinate benefits to reduce costs further. Generally, your plan covers first, and your spouse’s plan covers the remaining balance (up to the allowable limits).

4. Use Health Spending Accounts (HSAs) and Flexible Benefits

Some employers offer health spending accounts (HSAs), which can cover expenses insurance does not fully reimburse. If your workplace offers flexible benefits, you may be able to adjust your dental coverage annually based on your anticipated needs.

5. Request Predetermination for Major Treatments

For costly procedures like crowns or implants, your dentist can submit a pre-authorization request to your insurer, giving you a clear idea of what will be covered and what you’ll need to pay.

How Georgian Dental Can Help You Maximize Your Benefits

At Georgian Dental, we understand that navigating dental insurance can be confusing, and we’re here to help! Our team provides clear and transparent estimates before treatments, submits insurance claims on your behalf, and works with you to ensure you maximize your coverage.

Why Choose Georgian Dental?

• Expert Guidance on Insurance Claims – We help patients understand their policies and ensure they get the best reimbursement possible.
• Comprehensive Dental Care – From preventative care to advanced restorative treatments, we provide all the dental services you need under one roof.
• Flexible Payment Plans – If your insurance doesn’t cover a procedure fully, we offer financing options to help make dental care more affordable.
• State-of-the-Art Technology – We use the latest dental technology to ensure precise diagnostics and high-quality treatment outcomes.
• Personalized Care – We tailor our treatment plans to suit each patient’s unique needs, helping you prioritize necessary procedures while making the most of your benefits.
• Emergency Dental Services – If you experience a dental emergency, our team can help you get urgent care and work with your insurance provider to minimize your costs.

What to Do If You Have Limited or No Dental Insurance

If your insurance does not fully cover a necessary treatment, or you don’t have dental benefits, there are still plenty of options to manage costs.

Dental Payment Plans & Financing Options

Many dental offices, including Georgian Dental, offer flexible payment plans, allowing patients to spread the cost of treatments over several months. Third-party financing options, such as dental credit programs, can also help manage larger expenses.

Government Assistance Programs

Ontario offers some publicly funded dental programs for eligible individuals:

• Ontario Seniors Dental Care Program (OSDCP) – Free dental care for low-income seniors.
• Healthy Smiles Ontario – Covers basic dental services for children from low-income families.
• Ontario Disability Support Program (ODSP) and Ontario Works – May cover certain dental treatments for eligible individuals.

Discounted Dental Services

Some dental schools, like the University of Toronto’s Faculty of Dentistry, provide lower-cost services performed by supervised students. Additionally, some community health clinics offer sliding-scale pricing based on income.

Prioritize Essential Treatments

If you’re facing financial constraints, focus on addressing urgent dental issues first (e.g. infections, tooth decay, broken teeth). Preventative care should still be a priority, as delaying cleanings can lead to more costly problems later.

Bundling Treatments

Some treatments, such as multiple fillings or periodontal care, can be combined into fewer visits to help maximize your coverage while reducing overall costs.

Regular Oral Health Maintenance

Good oral hygiene at home can prevent costly treatments. Brushing, flossing, and using fluoride toothpaste can help you avoid issues like cavities and gum disease, reducing the need for expensive procedures.

Invest in Supplemental Insurance

If your employer-provided plans has gaps, or you have no insurance plan at all, consider purchasing additional private insurance or a Health Spending Account to cover out-of-pocket costs.

See If You Quality for the Canadian Dental Care Plan

The Canadian Dental Care Plan (CDCP) is aimed at addressing the essential dental needs of thousands of Canadians who might not be insured privately or face financial barriers.

However, it’s important to note that this doesn’t mean your dental services will now be free. Patients may need to pay out-of-pocket for additional services or fees that the government doesn’t cover. Families making more than 70,000 a year will need to pay a 40-60% co-pay. Therefore, it’s important to speak to your dentist and understand what is covered and what isn’t before having a procedure done so you’re not left with a surprise bill.

It’s also very important to understand that not all dentists will participate in the Canadian Dental Care Plan. Here at Georgian Dental, we are very proud to participate and make sure that everyone in our community can have access to dental care.

The CDCP is designed to assist individuals and families who face financial challenges when it comes to accessing dental care.

Eligibility criteria is as follows:

1.) Income-Based Eligibility

The primary determinant of eligibility is household income. The plan targets low to moderate-income families, ensuring that those who need financial assistance the most can benefit. Specific income thresholds are set annually, and families falling below these thresholds qualify for coverage.

For those making a family net income of less than $70,000, 100% of eligible dental services will be covered. For those making between $70,000 and 79,999, 60% of eligible dental services will be covered. Of those making between $80,000 and $89,999, 40% of eligible dental services will be covered.

At this point, any families making more than $89,999 will not be covered under the Canadian Dental Care Plan. This information could change as the program evolves, so it’s good to stay up to date and make sure you still qualify before booking an appointment.

2.) Age-Based Eligibility

Children under the age of 18 are automatically eligible for coverage under the CDCP. However, this is only if their family meets the income criteria. This is to ensure that all children can receive the necessary dental care to help support their growth and development.

3.) Special Populations

This plan extends coverage to special populations, including:

1. Seniors
2. Indigenous Peoples
3. Individuals with Disabilities

How to Apply for the CDCP Plan 

Applying for the CDCP involves a straightforward process designed to be as accessible as possible. Learn more about the CDCP or jump to the official CDCP Canadian Government site.

Georgian Dental is Here to Help You Get the Care You Need

Understanding your dental insurance and making the most of your benefits can save you money and help maintain your oral health. Be proactive, read your plan, use your coverage wisely, and explore alternative options if your plan is limited. By staying informed and working with Georgian Dental, you can ensure that you receive the care you need without unnecessary financial strain.

If you’re unsure about your coverage, talk to our team at Georgian Dental today—we’ll guide you through your insurance details, help with claims, and offer flexible solutions to fit your needs.