A dental insurance plan can help you manage the cost of routine exams, cleanings and X-rays. Most plans have a deductible and an annual coverage maximum.
Dental Preferred Provider Organization (DPPO) plans typically allow you to visit dentists outside of the network, but they may only pay up to a fee limit set by the plan administrator called a “table” or “schedule of allowance”. Some plans require a referral for specialists.
Preventive care
Dental insurance is a type of health coverage that helps pay for certain costs associated with preventive and basic restorative care. It is typically offered as a standalone plan, or as a rider to a medical plan. Most dental plans will have a monthly premium and a deductible that must be met before the plan begins to pay for procedures. Most also have copays, which are a set dollar amount that must be paid at the time of a procedure and can count toward meeting the deductible.
Preventive services are generally 100% covered by most plans. These include periodic checkups, cleanings, and X-rays. Most will also cover fluoride and sealants. Basic restorative services are usually 80% covered and include fillings, root canals, and dentures. Major restorative services are typically 50% covered and include crowns, bridges, implants, and dentures.
Most plans use the American Dental Association (ADA) three-four digit code system to define these types of procedures. Some will have additional categories that are not covered by all insurance companies, including orthodontics and oral surgery.
When choosing a dental plan, you should consider factors like waiting periods, deductibles, and annual maximum benefits. Most dental plans will have a provider network, so it is important to find a dentist that participates in the network of your choice. If you want the freedom to choose any dentist, a dental indemnity plan may be best for you. However, these plans often have higher out-of-pocket costs than DPPOs.
Basic care
Dental insurance is typically provided through a group program or as an add-on to an individual plan purchased in the Marketplace. It covers a wide range of preventive care and basic procedures, such as teeth cleanings and X-rays. It also covers more serious procedures, such as root canals and dentures. However, these plans often exclude orthodontics and cosmetic services, such as teeth whitening and braces.
Most dental plans work on a 100/80/50 model, which means that they cover 100% of preventive care and basic procedures, 80% of major procedures and 50% of the cost of specialty procedures, as long as you go to an in-network provider. They may also have an annual maximum, which is the amount they will pay toward dental expenses during a year. Some plans have a deductible, while others have coinsurance, which is a percentage of the costs you share with the plan after the deductible has been met.
Dental fees vary by location, but they can be fairly predictable if you have an idea of what dentists in your area charge. The ADA collects information on dental fees in various geographic areas and publishes it in its Survey of Dental Fees. You can use this information to compare dental fees in your area to find a good deal. In addition, if you have a high tolerance for cost-sharing and prefer a more diverse network of providers, a dental PPO or discount plan might be more appropriate for your needs than a traditional managed care plan.
Major care
Most dental insurance plans offer at least partial coverage for basic and major care, although every plan differs in the procedures they categorize as preventive, basic, and major. They also vary in how they handle costs like deductibles and copays (fees paid at the time of service) and how much of a benefit maximum, if any, is offered each year or lifetime.
Many traditional indemnity and preferred provider insurance plans (DPPOs) have a network of dentists that they contract with to obtain discounts on overall fees. When a patient goes to an out-of-network dentist, the amount of covered services may be reduced. Most PPOs also use a negotiated fee, known as a table or schedule of allowance, to determine a dollar amount for each type of procedure. The difference between the dentist’s actual fee and the insurer’s allowed charge is billed to the patient.
Depending on the policy, a DPPO’s annual maximum will usually be set at about 70% to 80% of a dentist’s fee for basic and basic procedures after the deductible is met. DHMOs typically do not have an annual maximum and will only cover 100% of a procedure after the deductible has been reached. In either case, patients will pay any remaining balance after the yearly or lifetime limit has been reached. This limit is reissued annually or sometimes at the end of each company fiscal year.
Out-of-pocket expenses
Dental insurance plans typically come with a deductible. This is the amount the patient has to pay out of pocket for expenses before the plan begins to share costs with the patient. Deductibles can be per person or family and usually only apply to basic or major procedures.
After the deductible is met, coinsurance and/or a policy maximum can come into play. The policy maximum is the maximum amount of coverage the dental insurance will provide in a year. Dental insurance policies with high annual maximums tend to have higher premiums.
Another way that out-of-pocket expenses can go up is through “downgrades.” For example, a dentist might charge $150 for a filling but the insurance will only cover $100 of the fee because they have chosen to use a less expensive composite (white) filling rather than an amalgam (silver color) filling.
Other out-of-pocket expenses can also include monthly insurance premiums and copays. In order to keep these costs down, it is important for the dental office and the patient to carefully review the benefits offered by each dental insurance provider. Licensed health insurance agents are available to help. In addition, many dental insurance providers offer stand-alone dental plans that can be purchased outside of the health insurance exchange/Marketplace and do not require the purchase of an overall health insurance plan.