Dental insurance helps overcome consumers’ biggest concern about getting needed care – cost. Plans vary by coverage type, monthly premium and deductibles.
For example, DHMOs usually have a lower dollar co-payment for basic procedures and a larger network than DPPOs. But DPPOs typically have a higher annual maximum. Plans also vary by whether they have a waiting period and what types of procedures are covered.
Coverage Options
Some health insurance plans include dental coverage as part of the overall plan, while others offer separate dental plans. When comparing these options, it’s important to pay close attention to deductibles, co-payments, annual maximums and monthly premiums.
Most dental insurance policies have a limit on how much they will pay toward a particular treatment over the course of a year, called an annual maximum. This limit may be based on the number of procedures or the dollar amount of care provided. Typically, most preventive and basic services will not reach this limit. In contrast, major procedures like crowns or dentures may easily exceed this limit.
Those who prefer more predictability of out-of-pocket costs should consider a dental Health Maintenance Organization (DHMO) plan, which usually offers low or no deductibles and capped annual maximums. However, patients will need to stay within the insurance provider’s network. Alternatively, consumers can opt for a Preferred Provider Organization (DPPO) plan, which usually has higher monthly premiums but also offers a larger network of dentists and providers. Some DPPOs have lower deductibles than DHMOs.
Deductibles
Often dental insurance plans have a deductible that must be paid before the plan starts paying for services. These deductibles can vary widely between different insurance plans and are usually a factor to consider when shopping for a plan. Plans with higher deductibles generally have lower monthly payments (premiums), but will require more out-of-pocket expense when you need coverage.
In addition to deductibles, Dental insurance policies may have other limits and restrictions that you should be aware of. These can include a maximum amount that the plan will pay for services during a year, and lifetime maximums for certain services such as orthodontics.
Many dental insurance plans also have frequency limits that restrict how often a service is covered. For example, a plan may only cover two cleanings per year or one panoramic x-ray every three years. Other common limitations are time limits for procedures such as a filling on a specific tooth or the number of crowns and bridges allowed on a particular tooth. These limits can be difficult to navigate, especially if you need frequent treatment.
Co-payments
The amount that a dental insurance plan requires the policyholder to pay for covered services before the plan starts paying. Usually, basic procedures have a low deductible and coinsurance, while major procedures require higher deductibles and more out-of-pocket costs. Many plans will not have a deductible for preventive services like routine exams and cleanings, as these are meant to encourage regular visits and help keep problems from developing.
Co-payments and coinsurance are not the same thing, although they do work together to lower the overall cost of a treatment. A co-payment is a flat fee, while coinsurance is a percentage of the cost of a procedure. The coinsurance amount is usually based on a standard fee (UCR) that dentists are charged by the insurance company.
Dental Preferred Provider Organizations (DPPO) and Dental Health Maintenance Organizations (DHMO) use negotiated fees to reduce the cost of dental care for their enrollees. These discounts can be quite significant and offer greater predictability for out-of-pocket costs. These plans also have lower deductibles and annual maximums than indemnity products, and most DHMOs don’t have an annual maximum limit.
Exclusions
Some dental procedures are not covered by insurance, either because they are considered elective or they are not medically necessary. Examples of such procedures include cosmetic treatments, dental implants, and treatment for gum disease.
Generally, insurance companies exclude these types of services because they believe the cost of providing them is not proportional to the benefits they offer. Other reasons for exclusions are based on time, such as the waiting periods that some plans impose to prevent individuals from enrolling in coverage and then canceling it when they have major dental work done.
Exclusions can seem like insurmountable obstacles when it comes to accessing affordable dental care, but they can also be useful for financial planning and understanding what your insurance actually covers. For instance, when a procedure is excluded from your coverage, it forces you to look for ways to pay for the service, such as by opening a savings account or seeking out low-cost clinics. It can also force you to consider other insurance options or negotiate with your dentist. In addition, a more holistic approach to dental health, including preventive care, can help you avoid the need for expensive or commonly excluded procedures.
Dual Coverage
Many dental plans exclude experimental procedures, and a few plans list other types of services as “non-covered.” Frequency and limitations of coverage are also important.
In the Marketplace, dental coverage is available either as part of a health plan or through separate individual dental insurance. Individuals may also choose to purchase a discount or referral dental plan, which is not technically insurance but does offer discounts on care at a set of participating dentists.
Clients with dual coverage need to inform their dental offices that they have multiple plans, so both insurers can coordinate benefits and minimize costs. They must also make sure that their secondary policy doesn’t include a non-duplication of benefits provision, which prevents the primary carrier from covering a service after the secondary policy has paid for it (and vice versa). Some plans have annual maximums that can overlap, and clients should consult their plan documents to determine whether this is permitted. They should also check the ADA’s survey of dentist fees for their area. These data are available online and allow consumers to compare the cost of common dental procedures.