People’s oral health needs vary, so finding the right dental insurance plan is essential. For example, a single person with a clean oral history would likely need a different plan than a family with children.
Most dental plans generally cover preventative services at 100% or with a small copayment. However, major restorative procedures tend to be covered only at 80% or 50%, with the patient paying the remainder.
Whether you are selecting dental insurance for individuals and families or evaluating a plan your employer offers, it is essential to understand the coverage provided by each option. The type of insurance, monthly premiums, deductibles, annual maximums, coinsurance, and treatment restrictions are all factors that need to be considered.
Dental insurance plans are typically categorized as either Indemnity (such as HMO plans) or managed care (such as PPO plans). These types of plans vary in their choice of providers, out-of-pocket costs, and how expenses are paid.
When reviewing a patient’s insurance details, it is also important to note the percentage of a particular procedure covered by insurance. This can be helpful for the patient and the dentist when discussing what to expect from a procedure and how much will need to be paid out of pocket. Also, it is essential to make sure that the remaining deductible and annual maximums are updated in your practice management software so that you can accurately calculate your patient’s out-of-pocket expenses. Having this information at your fingertips can help you provide better customer service.
Deductibles are the amount you pay for a service before your insurance company starts paying. For example, if you get a filling for $500 and have a dental plan with a $100 deductible, you must pay the first $100 before your insurance company covers the anything remaining.
Some dental plans require a deductible, while others don’t. Also, some dental insurance policies have a flat fee per visit/treatment called a copay. Copays don’t count towards your deductible, but they still have a limit, and you will be responsible for paying any expenses beyond that amount.
Most dental insurance policies have an annual maximum, the amount the insurer will pay for a specific year. For example, a policy with a yearly maximum of $1,000 per individual will stop covering costs after that amount is reached. However, some services, such as whitening and dental implants, are excluded from the maximum. Also, some plans have frequent limitations covering specific procedures, such as two yearly cleanings. This is important because it can help you decide between a lower premium and a higher deductible or a higher monthly fee with no deductible.
When patients decide what plan to select, they need to consider their individual or family oral and dental needs, current and expected. For example, a family of four may have one child with gum disease and another who will need orthodontics. They would need to look at a plan with high annual limits and low deductibles to help minimize costs while covering a significant portion of their non-preventive procedures.
It’s also essential for patients to understand the percentage of a procedure that insurance will cover (often called the “benefit allowance“). This information is provided after every visit in the Explanation of Benefits, or EOB. Patients should ensure they understand this number, which will help them budget and determine if their chosen plan fits their financial and healthcare goals. For example, an indemnity plan will be the right choice if they want the flexibility to choose any dentist they like. At the same time, a dental health maintenance organization (HMO) with a more extensive network size is a good fit for a family on a tight budget.
The size and scope of a dental insurance provider network can significantly impact cost. When evaluating options, it’s essential to consider the number and type of dentists within a network and how much coverage is provided for out-of-network visits.
Some plans use networks to keep costs low by negotiating discounts for services with providers in the network. These lower rates can make a significant difference in total costs for patients.
For example, a Healthcare DPPO network gives members access to quality dentists nationwide. It covers certain preventive care services at little to no extra cost when visiting an in-network dentist. Dental HMOs typically have limited networks and require members to remain in-network for all covered services.
Regardless of where you purchase a dental plan, thoroughly understand your or your family’s oral health and coverage needs before open enrollment begins. This will help you determine if a dental plan is right for you and your budget. If you’re enrolled through your employer, ask your HR representative for guidance during the annual open enrollment period.