How can dental insurance best serve you?

Ensuring you get the most out of your dental insurance policy requires some thought.

• To be best served by dental insurance, a patient must first understand what dental insurance offers. Every dental insurance company offers a different policy. Know that no “one size fits all” insurance policy exists.
• Dental insurance policies pay out differently from company to company. Knowing how an insurance company pays claims will give the patient much information about how a policy works. 
• Know terms such as PPO, DHMO, Medicare, Medicaid, and indemnity dental plans. Don’t worry; all this will be explained!
• Know your individual and your family’s dental needs. Everyone will need routine X-rays and cleanings. Everyone may not need braces, dental implants, or wisdom teeth removed.
• Know what your dental office will accept. Simply ask the office manager before your appointment, and they will review what is and is not covered.

This is a math problem. The factors are the insurance company, yourself and your family, and what your dentist’s office will accept. Understand the factors, and you will better understand dental insurance coverage.

What is a PPO?

PPO stands for Preferred Provider Organization. 

In a PPO, insurance companies will contract with various dentists (providers) who agree to discounted service rates. 

Typically, a PPO will offer these benefits to the patient:

• 100% coverage for preventative and diagnostic procedures
• 80% coverage for basic dental procedures
• 50% coverage for major dental procedures
• 50% for orthodontics
• A maximum the dental plan will pay in a year such as $1500 or $2000

PPOs are designed to keep costs under control so these savings are passed on to patients.

What is a DHMO?

DHMO stands for Dental Health Maintenance Organization. 

A DHMO controls costs even more than a PPO by limiting service to only chosen dentists with a scheduled rate of fees.

In addition to a premium, patients pay a preset co-payment for services. As a result, costs are predictable for the insurance company and the patient.

An essential feature of a DHMO is that costs are predictable. The predictable nature of the expenses makes DHMOs popular with many patients.

DHMOs are often called capitation plans since every patient pays a monthly fee to the dentist’s office. These fees are paid even if services are not rendered. The insurance company then pays the dentist’s office those fees only, no claims are paid. The monthly fee the insurance company pays is called a capitation check.

The downside of a DHMO is that services are only paid for if the dentist is a network member. 

What is Dental Indemnity Insurance?

A dental indemnity insurance plan reimburses a patient, on a limited basis, for services rendered by their dentist. 

The amount paid by the insurance company is based on the insurance company’s definition of what is “usual, customary, and reasonable” (UCR). Since the cost of UCR is created by the insurance company, fees can vary from one insurance company to another.

Dental indemnity insurance plans do not limit patients in their choice of dentists. Patients are free to choose any dentist but are only entitled to payment for services as set by the insurance company. 

Does Medicare have dental insurance?

Unfortunately, Medicare does not cover dental care. Read more about Medicare here.

Is there a group dental insurance that is like group medical insurance?

The answer is yes and no. Group dental insurance does exist, but it is up to your employer to offer this as a benefit. Check with your human resources department to see if this benefit is available.

If you have group dental insurance, it will work the same way an individual dental insurance policy would. There will be a premium, deductibles, co-pays, etc.

There is no one-size-fits-all type of group dental insurance policy. There are hundreds of choices on the market. Within one insurance company, there can be several choices of group dental insurance that your employer can choose from.

Read your policy and direct questions to your human resource department or the insurance company before you visit your dentist.

What is COBRA dental insurance?

COBRA, or the Consolidated Omnibus Budget Reconciliation Act of 1985, stipulates:

• Employees for companies with 20 or more employees can continue coverage after employment with the company
• Benefits are available to employees who quit, are laid off, or are fired.

The former employee will be required to pay a premium to the insurance company. Employees can find this expensive as their employer was most likely paying a large portion or all of their premium when employed by the company.

The insurance provider will contact the former employee with information on obtaining coverage through COBRA.

What is a dental insurance waiting period?

The Affordable Care Act mandates that the waiting period for a group dental or medical insurance policy can be 90 days at maximum.

A waiting period is a period of time in which a dental insurance policy does not cover some or all services. 

The waiting period includes preexisting conditions. For example, if you have a missing tooth, you must wait 90 days before coverage for treatment will be paid by an insurance company.

What is full coverage dental insurance?

Full coverage dental insurance is a term people misuse.

In reality, there is no such thing as full coverage dental insurance. 

Everyone is different. Therefore, everyone’s dental insurance needs are different. A young family may need coverage for braces. Whereas an older person may be interested in coverage for dental implants for missing teeth.

Most dental insurance plans cover the basics, such as six-month cleanings, X-ray, and checkups. Beyond the basics, you should know your policy before going to the dentist.

What is a dental savings plan?

A dental savings plan is sometimes called a dental discount plan.

Usually, there is a fee to join a dental savings plan. The fee is to administer the network of dentists part of  the plan. 

Dentists within the network agree to charge discounted services. These services can vary from plan to plan but have features such as: 

• Prescription benefits
• Wellness benefits 
• Expanded network benefits.

A dental savings plan is much like purchasing a Costco membership. After purchasing your plan, you receive discounts on merchandise. With a dental savings plan, you receive discounts on dental services rendered.

How long can an adult child stay on a parent’s dental insurance?

The standard age for adult children to receive coverage from a parent’s dental insurance policy is 26. 

Some states mandate the age 26, but insurance companies have made the age 26 the standard age to which coverage is extended.

Coverage applies even if you are:

• Married
• Become a parent
• Living outside of your parent’s home
• Attending school
• Covered by another from your employment (double coverage)
• Not financially dependent on your parents

Is oral surgery covered under medical or dental insurance?

There is no one-size-fits-all medical or dental insurance coverage for oral surgery. Four items determine coverage for oral surgery.

• Your medical insurance. Medical insurance can have some coverage for oral surgery for complicated procedures such as wisdom teeth removal, tissue biopsies, correction of facial deformities, or cancer-related issues
• Your dental insurance. Dental insurance will list available coverage. Usually, diagnostics are covered, but the oral surgery itself will fall under medical insurance.
• Your dentist. Your dentist will determine if oral surgery is necessary. Your insurance company may exclude your dentist after diagnostics are rendered, so knowing what your insurance covers is essential. 
• You. After considering all the above, you make the final decision.

As with any surgery, discuss what is covered before the surgery. Check with your provider’s office and your insurance company.

What is the maximum a dental insurance policy will pay?

For most dental insurance policies, the maximum a policy will pay annually is usually $1000 to $2000. Read your policy to see what your maximum payout is.

That said, most people do not hit those limits in a year.

Can two dental insurance policies cover you?

Yes, but there are a few things you need to know.

First, one plan is designated as the primary insurance. This insurance is billed first.

Second, the other plan pays on the balance.

Two dental policies are not uncommon. For example, a person can have two jobs or be covered by a spouse or parent’s policy. 

Your plan will have a Coordination of Benefits (COB) provision it. Consult your plan, and it will direct you on how to execute your COB.

What is a direct reimbursement plan?

A direct reimbursement plan is not an insurance plan run by an insurance company.

Your employer runs a direct reimbursement plan.

A direct reimbursement plan typically pays out between $1000 to $1500 annually. 

A typical plan will pay out as follows:

• 100% on the first $100 spent on dental services
• 80% of the next $500 spent on dental services
• 50% on the next $1000 of dental services. 

Some plans are structured to pay for dental services directly to the provider.

Check your plan to see if the employer pays directly or if you pay and then are reimbursed later.

What is a schedule or table of allowance dental program?

A schedule or table allowance dental plan often supplements a primary dental insurance program.

Dental services are reimbursed up to the maximum scheduled amount specified in advance. With an organized plan, you know exactly how much the plan will pay in advance.

What is the difference between a copay and a deductible?

A copay (or copayment) is a fee you pay every time you visit the dentist’s office or for every individual prescription filled at the pharmacy. Usually, these are small fees paid directly to the dentist or pharmacy. 

Copay fees are listed on the patient’s insurance card.

A deductible can be required in addition to a copay. The deductible is a set amount and is based on services used during the year. Once you fulfill the deductible amount, your share of the cost is met for that year.

Insurance plans are often structured to require a copay and a deductible.

What is coinsurance?

There are four times when the patient may have to pay out of pocket for dental-related services.

• Payment of your premium by you or your employers. A monthly payment is required by your insurance company to purchase your dental insurance policy. 
• Copayments are sometimes required. Some plans require a small copayment that is due at the time services are rendered by your provider. 
• Deductibles are paid up to a set amount. A deductible is your share of the cost of actual services provided. You will only pay the specified amount in a year. For example, if your deductible is $250, you will pay the first $250 for dental service that year.
• Coinsurance is based on a percentage of services. Once you pay your deductible, you may be required to pay a percentage of the balance. For example, if your coinsurance is 20% and you have a $ 1,000 dental bill, you would pay $200 after the deductible is met, and your insurance company would pay $800.

Coinsurance is not part of every policy. All the above vary from one insurance company to another. Make sure you read your policy and ask your insurance company to review any questions you may have regarding payment.

What is a preexisting condition?

A preexisting condition is something you were already diagnosed with before the beginning of your insurance plan. Fixing the condition may not be covered after a period of time or excluded altogether from coverage by the insurer.

The Affordable Care Act (ACA) outlawed preexisting conditions for medical conditions. It is important to remember that the ACA was written with medical insurance in mind and should not be confused with dental insurance.

Most dental care is designed to be preventative. Dentists aim to prevent conditions such as tooth decay or gum disease. As a result, dental insurance aims to facilitate preventative care. 

For example, many dental insurance plans have a missing tooth clause. Replacing that tooth would require a dental implant or a bridge. A dental insurance policy may exclude those conditions since they already occurred and are not preventable. In this example, you must pay for the expense out of your pocket.

What is a waiting period?

When a preexisting condition is listed in an insurance plan, a period is designated in which the insurance company will not pay for services. For example, your policy may state that you need to wait six months before treatments such as a root canal or crown are covered.

In addition, prosthetics such as crowns and dentures often have waiting periods before they are replaced. This can be five years for crowns and dentures. For example, if you received a crown three years ago, you would have to wait two more years before a policy would pay for a replacement crown. 

Make sure you know what your waiting periods are in your dental insurance policy. 

What does “usual, customary, and reasonable (UCR)” mean in an insurance policy?

Usual, customary, and reasonable (UCR) considers what providers charge for fees in a given geographic area.

For example, in New York City, where rents and other overhead are more costly, UCR would be higher. In a rural area where overhead is lower, the UCR would reflect lower charges.

UCR is not an exact amount. As a result, one insurance company may have a different definition of UCR than another. The definitive answer is your individual insurer’s definition.

Does dental insurance cover everything my dentist recommends?

Dental insurance is designed for preventive care of the teeth and gums. Coverage includes routine cleanings, exams, X-rays, and cavities.

Cosmetic services such as teeth whitening or crowns are usually not covered. 

Even though a dentist performs certain procedures routinely does not mean those services are covered by your dental insurance.

Does dental insurance cover wisdom teeth removal?

Wisdom teeth removal is not required by law for a dental insurance policy, but many plans offer some benefits. 

Typically, those benefits provide 50% to 80% of the cost. Just remember copays, deductibles, and coinsurance can be part of your share of the cost.

Medical insurance can also offer benefits if an oral surgeon is required. If dental and medical insurance are combined, you may have the cost of wisdom teeth removal fully covered.

Make sure you consult both your dental and medical provider to see what benefits are available for wisdom teeth removal.

Does dental insurance cover braces?

Usually, braces are not covered by a dental insurance policy. Some policies offer nominal benefits. Purchasing a dental insurance policy for braces only coverage would not be worth it.

A strategic way to pay for braces could be through a savings plan. 

Braces are considered cosmetic and, as such, are not covered by dental insurance.

Take Away Tips

Dental insurance varies from insurance company to insurance company. Also, remember that dental insurance is also legally administered by states. As a result, dental insurance from the same insurance company in different states can vary.

Make sure you read your individual policy yourself. The insurance company for a group or individual policy will have customer service that can help answer questions. 

For a group dental insurance policy your human resource department can help answer questions about your work-provided dental insurance.

Financial option information from Whiteridge Aesthetic Dentistry

Serving the Salt Lake Valley, Cottonwood Heights, Mill Creek, Park City, Summit County, Elko Nevada, West Wendover Nevada, and Evanston Wyoming