Understanding Dental Insurance Plans
Types of top dental plans
Indemnity plans offer a broader selection of dental-care providers than managed-care plans. Indemnity plans pay their share of the costs for covered services only after they receive a bill (which means that you may have to pay all of the costs up front and then bill your insurance company, which then reimburses you for covered charges).
Managed-care plans typically require you to use a dental provider network. Dentists participating in a network agree to perform services for patients at pre-negotiated rates and usually submit the claim to the dental insurance company for you. Managed care plans typically come in two varieties: health maintenance organizations (HMOs) and preferred provider organizations (PPOs).
Dental Insurance Cost and Coverage
The price you pay for your dental insurance is called the “premium.”
Most dental insurance policies cover 100% of the cost of preventative care such as cleanings, checkups and x-rays, 80% of basic treatments such as fillings, and 50% of the more complex procedures such as root canals and crowns.
So let’s crunch some numbers: two checkups and cleanings and a set of X-rays will cost, on average, from $375-$400, according to the American Dental Association. So your dental insurance policy enables you to pre-pay for your essential preventive care, plus you know that if you need a couple of fillings, or chip a tooth, you’re also covered.
Dental Insurance Maximums – Annual Caps
But wait … what about the costly treatments such as root canals and crowns? The amount of coverage you can expect for these sorts of procedures depends on the annual maximum coverage provided by your plan, also known as the “annual cap.”
Dental insurance policies generally limit coverage to $1000 -$1,500 a year. When your dental costs for most procedures go over that limit, you then have to pay for your own dental care out of pocket for the rest of the year.
The average cost for a crown is $750-$2000 per tooth, and the cost of a root canal is $750-$1,000 per tooth. Obviously you can exhaust your annual dental coverage of $1000-$1500 fairly quickly. If you know you’ll need major work at some point in the future, you may want to look for a policy with a high cap. You’ll pay higher premiums, but you may not max out your coverage in one visit.
Also, you can talk to your dentist about scheduling treatments in line with your dental coverage. For example, if your plan provides a year’s coverage starting in January and you need a root canal and crown that will cost about $3,000 you might be able to get $1500 worth of care in December, and finish your treatment in January. That’s assuming, of course, that you have your full annual maximum unused by the end of the year, and are willing to exhaust your coverage at the beginning of the next year.
Dental Insurance Limitations
There are, however, certain limitations and exclusions in most dental insurance plans that are designed to keep dentistry's costs from going up without penalizing the patient. Some plans may totally exclude certain services or treatment to lower costs. Know specifically what services the plan covers and excludes. All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes dental coverage and medical health insurance may overlap. Read and understand the conditions of your dental insurance plan. Exclusions in your dental plan may be covered by your medical insurance.
Dental Insurance Deductibles
Your plan’s deducible is the amount that you will have to pay out of pocket for dental services before your insurance will begin to cover a portion of your dental care costs.
The typical deductible is $50 for an individual annually, and $150 for a family. Some plans exclude preventive care from the deductible, which means these procedures are fully covered even if you haven’t met your deductible. So make sure to get that preventative care – your checkups, cleanings and x-rays. Being proactive about dental care is very important for your oral and overall health, and saves you money in the long run.
Dental Insurance Waiting Periods
Another thing to consider if you’re delaying seeing your dentist is that dental insurance may not provide immediate coverage for pre-existing conditions. With a new-to-you plan, you’ll usually have to wait six months for basic restorative services or a year for major restorative services.
Dental insurance often will not pay to restore teeth that were decayed, broken or missing before you purchased the policy, and may not play to complete any dental care treatment that was already underway prior to the policy going into effect.
There are some exceptions to the waiting period imposed for major procedures; a few insurers will waive their wait period if you can provide proof of continuous dental insurance coverage within 30-90 days prior to your purchase of their policy. This is a feature to look for if you want to switch insurance providers, or if you’ve lost your employer-provided coverage.
If braces, dentures or bridges are something you or a loved one does or will likely soon need, make sure the plan you choose covers these particular procedures. If you’re an adult who is considering orthodontia, make sure the policy covers orthodontic services for all ages, not just for children.
Also look at the waiting period for getting the treatments you know you’ll need, and see if you can realistically wait that long to get care.
In or out? Dental Insurance Networks
A dental insurance plan’s network is comprised of all of the dentists that have agreed to accept the discounted rates negotiated by the plan’s provider.
It’s important to note that a dentist may accept an insurance plan, but may not honor the negotiated rates – so you typically get the greatest savings from your plan’s in-network providers. Some plans do not cover care provided from a dentist outside their network, so check with your provider before you head to the dentist’s office.
If you already have a dentist that you want to continue to work with, ask him or her what insurance plans they accept and which one they recommend for you.
Predetermination of Costs
Some dental insurance plans encourage you or your dentist to submit a treatment proposal to the plan administrator before receiving treatment. After review, the plan administrator may determine: the patient's eligibility; the eligibility period; services covered; the patient's required co-payment; and the maximum limitation. Some plans require predetermination for treatment exceeding a specified dollar amount. This process is also known as preauthorization, pre-certification, pretreatment review, or prior authorization.
Key Features to Consider When Selecting a Dental Insurance Plan
In reviewing and comparing dental insurance plans, consider the following when determining whether the coverage will satisfy your dental care needs:
Does the plan give you the freedom to choose your own dentist or are you restricted to a panel of dentists selected by the insurance company? If restricted to a panel, is your dentist on this panel?
Who controls treatment decisions -- you and your dentist or the dental plan? Some plans may require dentists to follow the "least expensive alternative treatment approach."
Does the plan cover diagnostic, preventive, and emergency services? If so, to what extent?
What routine treatment is covered by the plan? What share of the cost will be yours?
What major dental care is covered by the plan? What percentage of these costs will you have to pay?
What are the plan's limitations (a limit to the benefits for a procedure or the number of times a procedure will be covered) and exclusions (denied coverage for certain procedures)?
Will the plan allow referrals to dental specialists? Will my dentist and I be able to choose the specialist?
Can you see the dentist when you need to and schedule appointment times convenient for you?
Who is eligible for coverage under the plan and when does coverage go into effect?
Your dentist cannot answer specific questions about your dental insurance plan or predict what level of coverage for a particular procedure will be. Each plan and its coverage varies according to the contracts negotiated. If you have questions about coverage, contact your employer's benefits department, your dental insurance plan, or the third-party payer of your health plan.
Points to Consider About Dental Insurance
Patients and dental insurance plan purchasers should insist on regular reviews of premium levels to ensure that UCR or Table of Allowances payment schedules are equitable. This analysis can help optimize your benefit levels, ensuring that every dollar you spend is used wisely.
If you are covered under two dental benefits plans, notify the administrator or carrier of your primary plan about your dual coverage status. Insurance plan benefits coordination can help protect your rights and maximize your entitled benefits. In some cases you may be assured full coverage where plan benefits overlap, and receive a benefit from one plan where the other plan lists an exclusion.
It may be wise to choose a plan that imposes dollar or service limitations, rather than one that excludes categories of service. By doing so, you can receive the care that's best for you and actively participate with the dentist in the development of treatment plans that give the most and highest quality care.
To help stretch each dental insurance dollar, most plans provide patients and purchasers with special administrative services. Find out if your plan provides the following mechanisms to help you budget, analyze, and dispute, if necessary, the costs of dental care.
Sources: WebMD, DentalPlans.com, eHealth
