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Helping you understand dental
insurance, dental discount plans, and other dental plans is our top priority. Most individual
dental insurance plans require you to satisfy waiting periods and deductibles
before having major and sometimes even minor restorative work done. Discount
dental plans help make maintaining good oral health a lot more affordable. And,
with no waiting periods or complicated coverage procedures, dental discount
plans are about as simple as you can get.
Traditional
dental insurance is often perceived as the best way to pay for dental expenses.
And while dental insurance is an excellent option when sponsored by your
employer, it may not be very cost effective when you are paying for it.
How do discount
dental plans work? As we become aware about our oral health, there has been a
demand for affordable dental care. Discount dental plans are the newest option
for those without coverage. These dental discount plans are much cheaper than
traditional dental insurance, and also offer almost equal coverage for all
dental work, even cosmetic procedures not covered by standard indemnity dental
plans.
The catch is that dental discount plans are not really insurance at all. They
work more like club memberships, where the cost of membership (your "premium")
earns a steep discount on any club service (dental work) you buy. The discount
normally applies to all dental office services performed by an approved "plan"
dentist, but no procedure is covered completely.
What are the
ins and outs of
discount dental plans? When it comes to dental discount plans,
the good news is afford ability, breadth of services, and immediate coverage.
The bad news is greater financial risk and responsibility on your part.
Although the
monthly cost of most discount dental plans is very low compared to the price of
a traditional dental insurance or indemnity insurance policy, there's more
allover financial risk with a dental discount plan. No care is totally covered,
so an expensive procedure will mean a big out-of-pocket expense, even with the
dental plan. And even when undergoing a low-cost service (like cleaning), you'll
still be expected to pick up a part of the cost.
However, on the
plus side, discount dental plans are effective immediately - so are many
procedures you need now will be covered as soon as you buy the dental discount
plan. Traditional indemnity and/or insurance dental plans usually impose a
waiting period of between 6 and 18 months for any major procedure. The last
"pro" is that all good dental discount plans should come with a money-back
guarantee.
Indemnity Plans
This type of
dental plan pays the dental office (dentist) on a traditional fee-for-service
basis. A monthly premium is paid by the client and/or the employer to an
insurance company, which then reimburses the dental office (dentist) for the
services rendered. An insurance company usually pays between 50% - 80% of the
dental office (dentist) fees for a covered procedures; the remaining 20% - 50%
is paid by the client.
These plans
often have a pre-determined or set deductible amount which varies from plan to
plan. Indemnity plans also can limit the amount of services covered within a
given year and pay the dentist based on a variety of fee schedules. Some typical
features of these plans:
-
High
deductibles before coverage begins (well-designed plans don't apply the
deductible to preventive services)
-
Probationary
periods on certain procedures that last up to a year
-
Annual dollar
limit on benefits
-
Chose your
own dentist
-
Your average
monthly cost: $15 to $25
-
Companies
selling these plans are regulated by state insurance departments.
Dental HMOs
These insurance
plans, also known as "capitation plans," operate like their medical HMO cousins.
This type of dental plan provides a comprehensive dental care to enrolled
patients through designated provider office (dentist). A Dental Health
Maintenance Organization (DHMO) is a common example of a capitation plan. The
dentist is paid on a per capita (per person) basis rather than for actual
treatment provided.
Participating
dentists receive a fixes monthly fee based on the number of patients assigned to
the office. In addition to premiums, client co-payments may be required for each
visit. Some typical features of these plans:
-
Monthly
premiums (some require you to prepay a year's worth)
-
Co-payments
for office visits
-
Free
preventive or routine care
-
You must
select from an approved network of dentists
-
May have an
initial enrollment fee
-
Annual dollar
cap
-
Your average
monthly cost: $5 to $15
-
Companies
selling these plans are regulated by state insurance departments.
Preferred
Provider Organizations
Another true
insurance plan, a Preferred provider organizations ( PPO) falls somewhere
between an indemnity plan and a dental HMO. This plan allows a particular group
of patients to receive dental care from a defined panel of dentists. The
participating dentist agrees to charge less than usual fees to this specific
patient base, providing savings for the plan purchaser.
If the patient
chooses to see a dentist who is not designated as a "preferred provider," that
patient may be required to pay a greater share of the fee-for-service. A group
of dentists agrees to provide services at a deeply discounted rate, giving you
substantial savings — as long as you stay in their network. Unlike the more
restrictive DHMO, though, you can go out of network and still receive some
benefits. Some typical features of these plans:
-
Monthly
premiums
-
Annual dollar
cap
-
You must stay
within the approved network of dentists or pay higher deductibles and
co-payments
-
Your average
monthly cost: $20-25
-
Companies
selling these plans are regulated by state insurance departments.
Dental Discount
This type of
dental plan is not insurance. The managing organizations have negotiated with
local dental offices to establish a set price for a particular dental procedure
and offer deep discounts (some up to 70%) off the regular ADA pricing code.
This plan has
several advantages over traditional dental insurance plans, namely, there are no
exclusions for pre-existing conditions. This allows a patient to receive
immediate coverage for work without meeting any waiting period requirements.
Direct
Reimbursement Plans
A dental care
plan now coming into vogue is the direct reimbursement plan. This is a
self-funded benefit plan — not insurance — in which an employer pays for dental
care with its own funds, rather than paying premiums to an insurance company or
third-party administrator.
You, the
patient, pay the full amount directly to the dentist, then get a receipt
detailing services rendered and the cost, which you show to your employer. The
employer reimburses you for part or all of the dental costs, depending on your
specific benefits.
Your company might reimburse 100 percent of your first $100 of dental expenses
and then 80 percent of the next $500, and 50 percent of the next $2,000, with a
total annual maximum benefit of $1,500. Or it might reimburse only 50 percent of
your first $1,000, resulting in a $500 yearly cap.
Some typical
features of a direct reimbursement plan:
-
Neither you
nor your employer pay monthly premiums
-
Freedom to
choose any dentist
-
Typical
employer cost: depends on the number of employees and benefit caps
-
Benefits
usually capped at $500 to $2,000 annually.
Dental care is quite different
than medical care. Major illness can strike at any time and the costs can be
enormous. Most dental disease is preventable and treatment is predictable.
Regular checkups and professional cleaning can help maintain your oral health
and so dental benefits are written to encourage patients to seek preventative
care in order to prevent more serious dental problems.
What do you look for in
choosing a plan?
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 you have a family dentist with whom you
are satisfied, consider the effects changing dentists will have on the quality
or quantity of care you receive. Because regular visits to the dentist reduce
the likelihood of developing serious dental disease, it's best to have and
maintain an established relationship with a dentist you trust
Who controls
treatment decisions--you and your dentist or the dental plan? Many plans require
dentists to follow treatment plans that rely on a Least Expensive Alternative
Treatment (LEAT) approach. If there are multiple treatment options for a
specific condition, the plan will pay for the less expensive treatment option.
If you choose a
treatment option that may better suit your individual needs and your long-term
oral health, you will be responsible for paying the difference in costs. It's
important to know who makes the treatment decisions under your plan. These cost
control measures may have an impact on the quality of care you'll receive.
Does the plan
cover diagnostic, preventive and emergency services? If so, to what extent? Most
dental plans provide coverage for selected diagnostic services, preventive care
and emergency treatment that are basic for maintaining good oral health.
But the extent
or frequency of the services covered by some plans may be limited. Depending
upon your individual oral health needs, you may be required to pay the dentist
directly for a portion of this basic care. Find out how much treatment is
allowed in any given year without cost to you, and how much you will have to pay
for yourself.
-
Initial Oral
Examination----once per dentist
-
Recall
Examinations----twice per year
-
Complete
x-ray survey----once every three years
-
Cavity-detecting bite-wing x-rays----once per year
-
Prophylaxis
or teeth cleaning----twice per year
-
Topical
Fluoride treatment----twice per year
-
Sealants----for those under age 18
What routine
corrective treatment is covered by the dental plan? What share of the costs will
be yours? While preventive care lessens the risk of serious dental disease,
additional treatment may be required to ensure optimal health. A broad range of
treatment can be defined as routine. Most plans cover 70 percent to 80 percent
of such treatment. Patients are responsible for the remaining costs. Examples of
routine care include:
-
Restorative
care - amalgam and composite resin fillings and stainless steel crowns on
primary teeth
-
Endodontics -
treatment of root canals and removal of tooth nerves
-
Oral Surgery
- tooth removal (not including bony impaction) and minor surgical procedures
such as tissue biopsy and drainage of minor oral infections.
-
Periodontics
- treatment of uncomplicated periodontal disease including scaling, root
planning and management of acute infections or lesions
-
Prosthodontics--repair and/or relining or reseating of existing dentures and
bridges.
What major
dental care is covered by the plan? What percentage of these costs will you be
required to pay? Since dental benefits encourage you to get preventive care,
which often eliminates the need for major dental work, most plans are not
generous when it comes to paying for major dental work, most plans cover less
than 50 percent of the cost of major treatment.
Most plans
limit the benefits--both in number of procedures and dollar amount--that are
covered in a given year. Be aware of these restrictions when choosing your plan
and as you and your dentist develop treatment best suited for you. Major dental
care includes:
-
Restorative
care--gold restorations and individual crowns
-
Oral
Surgery--removal of impacted teeth and complex oral surgery procedures.
-
Periodontics--treatment
of complicated periodontal disease requiring surgery involving bones,
underlying tissues or bone grafts.
-
Orthodontics--treatment including retainers, braces and/or diagnostic
materials.
-
Dental
Implants--either surgical placement or restoration
-
Prosthodontics--fixed bridges, partial dentures and removable or fixed
dentures.
Will the plan
allow referrals to specialists? Will my dentist and I be able to choose the
specialist? Some plans limit referrals to specialists. Your dentist may be
required to refer you to a limited selection of specialists who have contracted
with the plan's third party. You also may be required to get permission from the
plan administrator before being referred to a specialist. If you choose a plan
with these limitations, make sure qualified specialists are available in your
area. Look for a plan with a broad selection of different types of specialists.
If you have
children, you may prefer a plan that allows a pediatric dentist to be your
child's primary care dentist. Since specialized treatment is generally more
costly than routine care, some plans discourage the use of specialists. While
many general practitioners are qualified to perform some specialized services,
complex procedures often require the skills of a dentist with special training.
Discuss the options with your dentist before deciding who is best qualified to
deliver treatment.
Can you see the
dentist when you need to, and schedule appointment times convenient for you?
Dentists participating in closed panel or capitation plans may have select hours
to see plan patients. They may schedule appointments for these patients on given
days, or at specified hours of the day, restricting your access.
Some dentist's
fees for seeing you on weekends or during emergencies are high than those the
plan allows. You may be required to pay additional costs yourself. If you select
these types of plans, have a clear understanding of your dentist's policies as
well as the plan's dentist-to-patient ratio. It's the best way to ensure your
access to care is not unduly restricted and that you are not surprised by higher
fees the plan does not cover.
Insurance
companies do their best to ensure that their policyholders understand their
plans and benefits, but it is up to an individual to make sure that they are
making informed choices. The differences in the various plans you can choose
from are:
-
The type of
third party funding the plan.
-
Methods of
selecting a dentist.
-
Compensation
of the dentist's services to you.
-
The
calculations of benefits and payments.
Understanding
these differences will enable you to make an informed decision when selecting a
dental plan that is best for you or your family.
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