Dental Insurance: Essential Guide to Dental Insurance Plans

Have you ever wondered why your dental insurance did not cover your dental cleaning in full? Or were you surprised to find that you owed more than expected for your dental treatment? Below you may find that your dental insurance plan is not benefiting you to the fullest. We will explain the different insurance plans available to individuals and families.

You will also see that your options could vary depending on your premiums paid. The dental insurance plan you choose from your employer could affect your out of pocket costs as well as the dental office you choose to go to. We will explain what in-network and out-of-network will mean to you, the patient.

Dental Insurance and Costs

Are you looking for a new insurance plan? There are many dental insurance companies to consider: Delta Dental, Aetna, Cigna, Metlife, Guardian, Blue Cross, Assurant and United Concordia. These are just a few dental insurance companies. Other options to consider are private dental carriers such as Aflac, Careington Dental and public health. Be sure to check each plan carefully to be sure you will be able to receive the care you are seeking. Some plans do require you to go to one particular dentist or will provide preventive care only.

Having an understanding about dental insurance can save patients possibly hundreds or thousands of dollars. These are a few questions that should be answered prior to scheduling a dental appointment:

  • Does your plan require you to go to one particular dentist?
  • Are you required to stay “in-network”?
  • Are you required to pay upfront and mail in receipts to a health savings account?

One of the first decisions in finding the right dental plan is to know if the dental office you are seeking accepts your insurance. It is very important for each patient to know the details of their dental insurance plan. Some dental offices will help you to understand the details of your particular plan, however there are many offices that expect you to do the research. If you wait until after treatment has been completed it could be a very costly mistake.

In-Network or PPO

In-Network is also known as a preferred provider plan (PPO). A preferred provider plan is when the dentist signs a contract between the dental office and the insurance company agreeing to provide dental treatment at a negotiated and/or reduced amount.

Indemnity Plan or Fee-for-Service (Non-PPO)

Patients will have the option to go to any dentist of their choice without having to worry about staying “in-network”. The dental insurance plan will pay a portion of the dental treatment received, however any amount above the usual, customary and reasonable amount will be the patient’s responsibility causing larger out of pocket expenses for the patient. Patients are generally happy to pay any out of pocket expenses for the the flexibility of going where they would like to go.

DHMO: Dental Health Maintenance Organizations

Also known as a capitation plan. A patient will be assigned to go to one particular dentist or group that is contracted with the insurance company. Once assigned to that dentist the patient will not be able to change dental offices for that plan year. Patients will choose this plan for financial reasons. The patient’s premium for a DHMO plan is usually substantially less than the other plans and the patient has very little out of pocket expenses to be paid.

HSA/Health Savings Account and FSA/Flex Spending Accounts

Both accounts provide tax advantages to the patient. Health Savings Accounts are typically set up when the insurance policy holder has a high deductible. This plan is able to be rolled over from year to year continuing to grow. Flex Spending Accounts are generally set up through an employer. It is critical that the participant estimate ALL medical/dental expenses for each year, at the end of the plan year what you do not use you lose.

A typical dental insurance plan consists of:

  • Yearly maximum ranging from $1,000 to $2,000 per calendar year
  • $50 deductible per person, $150 per family, waiving deductible for preventive treatment

Standard Dental Insurance Copayments:

  • Preventive treatment 100% (exam, cleaning, x-ray, sealant)
  • Basic 80% (composite filling, root canal, extraction)
  • Major 50% (crown, bridge, implant)
  • Orthodontics 50%

The copayments listed above are paid at a percentage called “usual, customary and reasonable” or UCR. These fees are determined by each insurance carrier and will differ from carrier to carrier based on the geographical area dental treatment is received. The copayment to be paid to the dentist completing treatment would depend on if that office is “in-network” or “out-of-network”, at times if the dentist is out-of-network the copayment may be reduced, for instance if basic treatment is completed in-network copay would be 80%, out-of-network could be 60%. If the dentist is in-network that dentist has signed a contract to accept the fee that particular dental insurance carrier has determined to be UCR.

When a job is lost, or a gap in between jobs occurs, dental insurance plans end. Cobra plans will be offered at the employee’s cost. Most plans have 90 days from date of termination to sign up to carry the cobra insurance. If the 90 days has lapsed, coverage under the previous plan will no longer be an option. This could be a very costly mistake. Not only will the cost of an individual plan cost more, most individual plans also have waiting periods that would not have been necessary had the original plan been kept in place. Take the time to research all dental insurance plans available, there are differences of plan payouts and premium costs.

So many individuals have dental insurance and are not taking advantage of this wonderful benefit by going to the dentist. Dental benefits are there to help cover some of the cost of dental treatment to help maintain good health. If out of pocket expenses are holding you back from going to the dentist, there are many options available to help cover those costs. Dental offices are happy to help individuals and families to receive the dental care that is needed to maintain good health. Don’t be afraid to ask the dental office how they can help you achieve this goal of good dental health.

Dental Insurance by State