Dental Insurance and Dental Plans
Dental insurance typically covers the majority of the cost of preventive care such as exams, cleanings, and x-rays. Family plans may also offer coverage for dental sealants and fluoride treatments to keep kids' teeth healthy. Plans generally cover some of the expense associated with basic dental procedures like gingivitis treatment, fillings, root canals, and extractions. Patients may have to pay a significant percentage of the cost of expensive treatments such as braces, crowns, bridges, or dental implants. Many insurance plans exclude a wide variety of treatments including cosmetic procedures like tooth whitening and veneers.
Most Common Types of Dental Plans
PPO Insurance: Employers who offer dental insurance often choose a PPO (preferred provider organization) plan. An insurance carrier contracts with a network of dentists who agree to provide services to members of the plan. These dentists typically discount their fees as a condition of being included in the network. Employees and employers both pay a portion of the insurance premiums for employee membership in the PPO. Members must generally choose a dentist in the network to avoid paying much higher fees for treatment or having their claims completely denied. The insurer typically pays for the portion of treatment that deductibles and copays do not cover for service rendered by an "in-network" dentist.
Indemnity Insurance: These traditional dental insurance plans allow members to choose any dentist. However, the payment of claims is more complex since the dentists have not agreed to a specific fee for their services. The insurer will only pay for their agreed percentage (such as 50-80 percent of the patient's costs) based on their own fee schedule. This is called paying for "usual, customary, and reasonable" fees. If a dentist charges more than the amount the insurer has determined as the typical, average cost for a treatment, the patient must pay the difference. These plans often require patients to pay a deductible and may place a cap on the maximum amount paid for services in a year or over the lifetime of the member.
Dental HMO: An HMO dental insurance plan pays participating dentists a fixed fee per member per month regardless of the services they require. Plan members pay a premium and copays. HMO plans don't have a deductible, but the copays may range from $5 to $1,000 per visit depending on the treatment the patient needs. Patients sometimes worry that they will not receive the treatment they need under an HMO because the dentist could choose to skimp on treatment to keep more profits. However, participating dentists actually stand to gain the most through correcting dental problems before they become severe and require more expensive procedures.
Discount Plans: Patients who don't have dental insurance coverage through an employer's group plan may have difficulty finding an affordable individual insurance plan. Discount (reduced fee) plans offer an alternative to traditional insurance. Patients typically pay at the time of service for the full amount of treatment fees minus the discount. They may choose a monthly payment plan to pay off more expensive procedures. Dentists who participate in these discount plans can reach a wider patient base and reduce the time consuming and expensive process of filing claims with traditional dental insurance carriers.
Pros and Cons of Dental Insurance
Dental insurance usually pays most of the cost of standard diagnostic and preventive treatment. This coverage makes it affordable for patients to protect their dental health throughout their lifetime. A plan that covers a portion of the cost of advanced treatments such as orthodontics and restorations can allow patients to fix misaligned, decayed, broken or missing teeth before these problems cause irreversible damage.
Dental insurance often restricts coverage for complex and expensive restorative procedures. For example, a dental plan may cover the cheapest restorative treatment options available but not the ones that tend to have the best outcome for the patient over the long term. Or, plans may put a cap on the amount reimbursed for dental services over the course of a year. Patients may have to delay treatment or have only one tooth fixed at a time leading to less than optimal results. Dental insurance typically won't cover cosmetic treatments. PPO insurance plans restrict which dentists a patient can see for treatment.
Cost of Dental Insurance
The cost of dental insurance varies depending on the extent of coverage offered and the number of family members on the plan. Employer sponsored plans are usually more affordable than individual plans. A dental indemnity plan generally averages from $75 to 150 dollars per month. Patients must also pay a deductible and cover a portion (often 50 percent) of the cost of major dental work. Discount plans may cost less than $10 per month. However, they may only offer a modest discount for dental services.