All About Dental Insurance

Find out everything you want to know about dental insurance, braces and orthodontics insurance. The costs, the benefits, maximizing the amount you get paid for dental treatment.

General Information On Dental Insurance

Dentistry is a medical discipline that addresses the oral health of an individual. Dental health also affects a person’s overall health and therefore, it is important for the entire population to maintain proper dental wellbeing. As dental procedures can become costly, it is best for a patient to consider dental health insurance as a cost effective option. Even for companies looking to purchase dental insurance, they must consider that insuring their employees will ensure less sick days. Dental coverage involves routines such as dental cleanings, cavity fillings, root canals, x-rays, crowns and braces installation.

Dental plans are similar to general health insurance plans. One of the deciding factors for many is the ability to choose a dentist without limitations versus having to choose a dentist from a specific list. Many of the established dental plans are designed to pay a portion of the cost of a dental procedure. It is very important to read the specific procedures that are covered in addition to what percentage and the annual limit. Some preventative procedures are covered without a coinsurance. If a patient were to know in advance what type of procedure he would require, it is best to ask the insurance company if this routine is covered. Also, patients are advised that there are some pre-existing conditions that may change coverage policy.

Dental insurers typically pay the “usual, customary and reasonable” (UCR) rate which is determined by dental plan administrators. This rate varies widely from plan to plan and must be very carefully considered by an employer electing dental coverage for their employees or an individual researching independent coverage. The UCR is the fee that the dental insurer sets comparatively to the average local dentist’s rate for the same procedure. Plans pay a particular percentage of the UCR while the patient is left with the rest of the bill. Some important points to review with an employer or dental insurer involve:

  • Is there the ability to choose a dentist?
  • Is the course of treatment chosen by the patient and medical provider?
  • Are emergency, diagnostic and maintenance procedures covered? Does it provide coverage for x-rays and cleanings?
  • Is major dental care covered in the plan including temporomandibular joint disorder? Are implants and dentures covered?
  • If a specialist is required, will he or she be covered under insurance and does the patient have the freedom to choose?
  • What is the emergency treatment coverage? What are away from home emergency treatment protocol?
  • What percentage of the premium goes to care versus coverage?

While there are many types of dental insurance plans, they can be divided into two categories: fee-for-service and managed care. Fee-for-service is a plan in which the patient has absolute freedom and the dentist is reimbursed on a service by service basis for his examination. Managed care plans keep cost effectiveness in mind and consider frequency of treatment, restriction of access to care and metering the reimbursement scale.

A PPO plan is a type of managed care service plan. A PPO or preferred provider organization program is when a patient agrees to choose from a list of in-network dentists. The in-network dentists are those who agree to the compensation they will receive in exchange for their services. If a patient receives treatment outside of the network, he will be penalized with higher out of pocket expenses. The patient agrees to pay a specific coinsurance payment for each service (e.g. 20%). Each dental service may be covered at a separate coverage percentage which should be in the terms and conditions of the policy. PPO plans generally have an out of pocket maximum after which an insurance company will incur all of the cost. Typically a monthly coinsurance is paid as well. Some important things to consider when determining whether a managed care system is best for an individual or employees are:

  • In terms of the premium, what percentage is directed towards care versus administration?
  • Is the employer at risk if the PPO plan persuades the patient to choose certain providers?
  • What are the selection criteria? Are there enough providers in the plan for adequate selection? Are there sufficient referral and specialist providers?
  • What are the allowances for emergency care?

    • The DHMO plan is a type of managed care dental health plan. A DHMO or dental health maintenance organization is when the plan pays a certain dentist a fixed fee for his services. In return for paying the flat fee, dentists agree to offer a certain type of treatment at no cost. DHMO programs reward providers who keep patients in optimum health so that the DHMO ends up paying less in emergency treatments. DHMO plans are usually the least expensive. Some factors that may influence the decision include:

  • What amount of the premium is used for administrative costs?
  • Does the purchaser or employer have the ability to access dental visit information on each employee?
  • What is the “utilization rate” for patients in this program? How long does it take to get an appointment and what is the wait time in between appointments?
  • What is the demographic of dental providers? Is there a low patient to dentist ratio?
  • How many patients have withdrawn from the program? What is the acceptance to application ratio of providers?
  • What is the compensation rate for dentists? What provisions are in place for emergency or unforeseen situations?
  • What level of specialist participation is there?

    • DR or direct reimbursement is a type of fee-for-service dental health plan. It is a self-paid benefit plan that reimburses patients directly on the dollar amount spent for the service regardless of the type of treatment given to the patient. It gives the patient the ability to choose any dentist without a monthly coinsurance. Employers will pay a percentage of the actual service provided which means if employees do not use dental services whatsoever, the employer will have no cost. There is also less pressure on the side of the employer as to what plan is the best for a multitude of employee situations.

    Another factor that many parents, adults and employers of families consider in dental insurance is braces. Potential patients must ask the insurance provider if they provide braces coverage and then at what rate. Because braces are considered “cosmetic” in nature, they are covered at a much lower percentage than typical dental procedures, however, the more severe the case, the more likely the insurer will cover the procedure. Severe orthodontic cases may affect oral health later in life and correcting the issue before it creates more problems is of concern to most dental insurance providers. Dental insurers will look at each patient in a case by case basis to determine whether or not the person will be covered. Because braces can cost over $5000, it is best to get insurance of some sort and asking an orthodontist may be the best place to start.

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