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Dental Insurance Plan Categories
Types of Dental Insurance
What Does Dental Insurance Cover
Coverage Limits
How Often Should You See Your Dentist
Predetermination of Costs
Peer Review for Dispute Resolution
Other Things to Consider
FAQs
The Bottom Line
Dental insurance plans work similarly in some ways to other types of health insurance. For example, as with health insurance, you’ll most likely need to meet an annual deductible for dental insurance policies. They also have benefit caps that set a limit on how much the insurance plan will pay for dental care, but unlike with health insurance, there is no maximum on how much you may have to spend out-of-pocket. But there are some big differences you’ll need to know about.
There are various types of dental insurance plans, and it’s important to learn more about them so you can get the coverage you need for all of your dental care needs
Dental Insurance Plan Categories
Although plan features might vary, the most common dental insurance plans fall into several categories:
- Direct Reimbursement Programs – With this plan category, you will pay a predetermined percentage of your overall dental care expenses, regardless of the type of dental care you receive. This plan category does not typically limit coverage depending on the type of treatment. This approach is meant to allow you to visit the dentist of your choice and encourage you to work with your dentist on healthy and cost-effective solutions to dental concerns.
- Usual, Customary, and Reasonable (UCR) programs – UCR describes the usual, customary, or reasonable cost of a particular service in a specific area; insurance companies will use this metric to decide whether a provider’s charge for a service is greater than, or less than, the maximum amount that they think should be charged. The three parts can be described as follows:
- Usual – The price of a treatment or service is considered “usual” if the cost is the same as what most providers typically charge for the same or similar services.
- Customary – Customary means that the cost of a service is within the range that most other providers in the region charge for the same or similar services.
- Reasonable – If the cost meets both the usual and customary guidelines or is a special service like a rare or difficult procedure, it falls under the “reasonable” guideline.
These plans will pay a portion of the service based on the UCR rate, and then you would need to pay the rest (your coinsurance). If the cost of the procedure is more than what your plan has decided is the UCR for that service, the plan would only cover you for the percent up to the amount of the UCR, and anything over that would be your responsibility.
For example, if your procedure costs $1,000 but the UCR is $500, and your plan covers 50% of the UCR, your plan would pay $250. You would pay $250 coinsurance and the remaining $500 out-of-pocket. Most plans will not count payments above the UCR towards your deductible, so only that $250 coinsurance payment would go towards your annual deductible.
- Table or schedule of allowance programs – Plans in this category establish a list of services that are covered at a set dollar amount, regardless of what your dentist charges. That amount is what the plan will actually pay for the services that are covered. You will be responsible for the difference between the allowed charge and the dentist’s fee.
- Capitation programs – These categories of plans pay contracted dentists a set amount per enrolled family or patient (often on a monthly basis). In exchange, the dentists agree to treat certain medical conditions without charging anything at the point of service. There can be a patient copayment for some procedures, though. The amount the plan covers for your actual dental care may be very different from the capitation premium that is paid.
Types of Dental Insurance
As mentioned, dental plans differ from health insurance plans in certain ways but are similar to them in others. As with medical insurance, you typically have the following choices with dental insurance:
- Preferred Provider Organization (PPO) – These plans include a list of dentists who participate in the plan, just like a PPO health insurance policy. Going outside of the network is an option, but your out-of-pocket expenses will be higher.
- Dental Health Maintenance Organization (DHMO) – These plans offer a network of dentists who accept the plan. You might need to pay a copay, although visits are free with some plans, similar to a health insurance HMO. Also similar to a health insurance HMO, it’s possible that you won’t be able to visit an out-of-network dentist.
- Discount or referral dental plan – This type of plan offers discounts on dental services from a specific group of dentists. A discount or referral plan does not cover your dental care. Instead, the dentists who participate have agreed to give you a discount on your dental care services.
What Does Dental Insurance Cover
Dental insurance typically covers a percentage of the cost of preventive care, crowns, fillings, root canals, and oral surgery, including tooth extraction. Plans may also cover prosthodontics, which includes dentures and bridges, orthodontics, and periodontics (the care of the structures that support and surround the tooth). Two preventive visits are typically covered every year.
It’s important to note that your plan might not cover periodontics and prosthodontics in the first year. Additionally, most insurance policies often require a rider for orthodontics. Which is an add on you can purchase for an extra cost.
Coverage Limits
Every plan has an annual maximum payout during a plan year, and for many plans, that maximum is extremely low. Any costs that exceed that amount are your responsibility. For example, some dental PPOs have yearly maximums of less than $1,500. This means you would be responsible for all costs above $1,500. You can easily reach that limit if you require an oral surgery, a crown, or a root canal.
Orthodontic costs typically have a separate lifetime maximum. To cut costs, certain insurance plans may completely exclude some services or treatments. Make sure to check the services that the plan includes and excludes.
There may be some less apparent exclusions. But all plans prohibit experimental procedures and services provided by or under the direction of a dentist.
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How Often Should You See Your Dentist
Having a good dental insurance plan means you can get the preventive dental care you need. But how often should you see your dentist? Adults should typically visit their dentists twice a year, according to experts. Dental insurance policies encourage this, although sometimes the wording of the policy varies. Your policy may say it covers preventive visits once every six months, twice a year, or twice every twelve months.
Other services like X-rays, fillings on the same tooth, crowns and bridges on the same tooth, or fluoride treatments for kids typically have time restrictions, as well. For instance, your policy might only cover a complete set of X-rays every three years.
Predetermination of Costs
Some dental insurance policies recommend that you or your dentist submit a treatment proposal to the administrator of the plan before beginning a treatment. Your eligibility for treatment, the amount of time you will be eligible, the services that are covered, your co-payment, and the limit on coverage, could all be decided by the administrator. For treatments costing more than a certain amount, some plans require pre-authorization, precertification, or pretreatment evaluation.
Peer Review for Dispute Resolution
If you feel like your dental insurance has not covered your services in the way it should, or you didn’t get the care you should have, you can take the case to peer review. Peer review mechanisms are common in dental insurance policies. They settle disagreements between third parties, patients, and practitioners, so that everyone can avoid pricey court cases. Disagreements tend to happen over fairness in fees and quality of care if that patient feels they were charged too much or didn’t receive proper care. Most disagreements happen between the patient and the dentist. But sometimes the insurance company can also decide that a fee was too high. Or that the patient did in fact receive improper treatment.
There are two phases to a peer review. The first phase is mediation. Where the patient and the dentist, or the insurer and the dentist, try to come to an agreement with the help of a mediator. If they can’t, the dispute goes to phase 2. In this phase, a committee of state and local society members will review the case. Then they will make a judgment based on the facts they’re provided.
Peer review works to ensure fair, individual case attention, and a comprehensive assessment of the documentation, medical practices, and outcomes. Peer reviews can settle most disputes in a way that is acceptable to all parties.
Other Things to Consider
If your employer provides dental insurance, that’s probably your best option when it comes to dental insurance. Generally, participating in employer-provided dental insurance is less expensive than purchasing a policy on your own. If your employer does not offer dental plans, and you already have a dentist, your dentist might be able to suggest a plan based on your dental history if you’re looking for your own plan.
When comparing plans, consider the following factors:
- If your dentist and specialists are in-network
- Total costs for the plan each year, including premiums, copays, and deductibles
- Annual maximum
- Out-of-pocket limit, if any
- Limitations on pre-existing conditions
- Coverage for braces
- Emergency treatment coverage
- If you can choose your own dentist
- Who controls treatment decisions: you and your dentist, or the dental plan
- If the plan covers diagnostic, preventive, and emergency services, and how much
- Who is eligible for coverage under the plan, and when coverage goes into effect
FAQs
Can I buy dental insurance without health insurance?
You can get dental insurance even if you don’t have health insurance. When you buy health insurance, it doesn’t come with dental coverage by default.
Dental insurance is different from health insurance in that you can buy it at any time of the year and from any insurance company. You don’t have to get your health and dental insurance from the same company. Make sure that the plan you choose gives you and your family the coverage and benefits you need.
Does the ACA require insurance to cover dental?
No, dental insurance is not covered by the Affordable Care Act (ACA). But there are some situations in which you can buy dental insurance from the Marketplace.
Is dental insurance worth it?
Yes, it is worth it to have dental insurance. In many cases, the cost of your annual premium is less than the cost of two regular trips to the dentist per year. Taking care of your teeth is an important part of being healthy. As your kids grow, it’s important to take care of their teeth regularly. Dental insurance helps pay for preventive care and lowers costs if something unexpected happens, like breaking a tooth or getting a cavity.
The Bottom Line
Having dental insurance may not always seem like a necessity. But it really is, since your dental health can affect your overall health. If left untreated, oral issues like gum disease can cause heart problems, strokes, and respiratory issues. Having dental insurance will allow you to keep your mouth, and body, healthy without having to worry about expensive medical bills.
