Dental insurance is a form of health coverage that typically comes with deductibles and coinsurance. It also has an annual maximum that dictates how much the plan will pay for treatment.
There are many types of dental plans that offer different options and coverage limits. These include dental Preferred Provider Organizations, dental HMOs, and dental indemnity insurance.
Coverage
Experts recommend that adults visit the dentist for routine cleaning and exams at least twice per year. Dental benefits typically cover these preventive services, usually without a waiting period. However, coverage can vary significantly by plan. In addition, most dental plans limit the number of procedures or dollar amount of work that is paid in a year.
Whether you choose a dental health maintenance organization (DHMO) with a provider network or a fee-for-service plan that does not, most plans include a coinsurance provision to help control costs. Coinsurance is a ratio that indicates what portion of the cost of a service a dental plan covers after you meet your deductible.
Some people purchase separate dental insurance to complement their health coverage, either through employer-sponsored or individual policies, or through the public health insurance exchange/Marketplace. Currently, you can only buy stand-alone dental insurance in the Marketplace if you also purchase a health plan. Depending on your preferences and budget, you can find many different plans in the Marketplace that offer differing levels of coverage. Higher coverage levels come with higher premiums, while lower coverage comes with lower deductibles and copayments.
Deductibles
Whether you have dental insurance offered by your employer, purchased in the private market through a dental PPO or as part of a Medicare Advantage plan, it’s important to know how deductibles, copays and coinsurance work. These factors are what determine how much you pay out-of-pocket for a given treatment and help to decide if a particular policy is right for you.
Deductibles are a set amount that you pay each year before your plan begins to cover costs. These are generally pretty low and many plans offer preventive care without a deductible at all.
A deductible can be applied to basic services like fillings and extractions as well as major procedures such as crowns or root canals. Many plans also limit the number of times that a specific procedure is covered in a calendar year (although experts recommend seeing your dentist at least twice a year).
Co-payments
Dental insurance plans may provide copays to help pay for treatment costs. These are generally fixed fees for specific services, such as x-rays or office visits. Some plans also allow enrollees to receive services outside of the contracted network for a higher fee. Generally, these are referred to as “discount” or “referral” plans and do not qualify as true dental insurance.
Many dental insurance plans also provide coinsurance, which is a percentage of the cost of covered procedures after the patient has satisfied their deductible. Coinsurance is typically expressed as a percentage of the procedure fee, but some plans use flat dollar amounts instead.
Some dental insurance plans have no deductibles at all, which allows for more affordable coverage for preventive services such as bi-annual cleanings and exams. Some also have an annual maximum, which limits the amount of money that the insurance company will pay for dental care in a year. Most dental plans operate on either a calendar or fiscal year schedule. It is important to understand these differences when selecting a plan.
Networks
A dental insurance network is an agreement between a benefits carrier and a group of dentists who agree to provide discounted services to the carrier’s insured patients. In return, the carrier offers to reimburse the dentist a percentage of their fee schedule. This frees the dentist from having to negotiate fees for each individual procedure with each patient. Preferred provider organization (PPO) plans and employer tables of allowance are the most common types of networks.
Dental practices are looking to maximize reimbursements from their insurance companies and remain financially profitable. Being in a network helps by providing them with a steady stream of patients that can be seen at a pre-negotiated reduced rate.
Being in a network doesn’t mean that you won’t see patients with other types of plans. In fact, most practices accept a wide range of plans and still provide quality care to those who choose to pay out-of-pocket. However, being in a network helps your practice to become more visible to patients with certain plan types and encourages them to make appointments quickly.
Exclusions
Dental insurance is designed to keep your mouth healthy, but there are many services that it excludes or limits. Some of these include root canals, orthodontics and certain dental procedures. It’s important for dental teams to understand these limitations so they can provide patients with accurate estimates and prevent claim denials.
Another common limitation is the annual maximum. This is the cap on how much a plan will pay in a year, and it is often quite low. This can make it difficult to cover expensive treatments such as crowns and root canals.
Also, some dental plans impose a waiting period before covering certain treatments. This is meant to prevent people from buying dental coverage only to have major treatment done. Waiting periods vary by insurer and can range from a few days to a full year.