What is Dental Insurance?
Dental insurance is designed to pay a portion of the costs associated with dental care. Generally dental offices have a fee schedule, or a list of prices for the dental services or procedures they offer.
Typical Types of Dental Insurance
Indemnity Dental Insurance Plan:
This plan may be helpful when you want to stay with your dentist and he/she does not participate in a dental network. By the very nature of this plan the insurance company generally pays the dentist a percentage of your services according to the policy you purchased. In addition you will want to review the co-payment requirements, waiting periods, stated deductible, annual limitations, graduated percentage scales based on the type of procedure and/or length of time you have owned the policy prior to starting your dental work. These are also known as “fee for service” plans. The plan pays the maximum allowable charge or the designated amounts/percentages per service, and operates without provider networks. You are usually required to pay the total cost of the bill at the time of service. The carrier will directly reimburse you the cost of the benefit once the claim is approved.
Dental Health Managed Organization (DHMO):
When a dentist signs a contract with a dental insurance company that provider agrees to accept an insurance fee schedule and give their customers a reduced cost for services as an In-Network Provider. Many DHMO insurance plans have little or no waiting periods, no annual maximum benefit limitations, while covering major dental work near the start of the policy period. This plan is sometimes purchased to help defray the high cost of the dental procedures. Some dental insurance plans offer free semi-annual preventative treatment. Fillings, crowns, implants and dentures may have various limitations.
Participating Provider Network (PPO):
Depending on your specific plan, the PPO works similar to a DHMO while using an In-Network facility. However, it allows you to use an Out-of-Network or Non-Participating Provider. Any difference of fees will become the financial responsibility of the patient unless otherwise specified in your dental policy. As noted, some dental insurance plans may have an annual maximum benefit limit. Thus, once the annual maximum benefit is exhausted any additional treatments may become the patient's responsibility. Each year that annual maximum is reissued. The reissued date may vary as a calendar year, company fiscal year, or date of enrollment based on your specific plan. This type of plan does not typically require referrals to see specialists nor do you have to elect a primary provider. Plans will pay for a portion of out-of-network benefits either based upon a specific level of what other local dentists charge or from a fee schedule. Therefore, you can save more money by seeing an in-network provider.
Special Note: Pay close attention to how out-of-network claims are reimbursed. Some types of PPO plans reimburse out-of-network charges based upon a fee schedule or charge amounts listed like a menu of benefits. (These are known as Fee Schedule or MAC Plans in employer-sponsored benefits.) We suggest that you use in-network providers with these plans. Or, you may receive a larger bill than expected with out-of-network providers.
Important Plan Terms
Don’t let insurance terms intimidate you. We’ve provided a high-level explanation of some basic dental plan terminology. This quick list may help you identify important elements of a dental plan.
PPO Network – An insurance company or preferred provider organization contracts with providers to participate in the network. In the contract, the provider agrees to charge the insurance company’s customer a set, discounted rate for certain services and procedures. Therefore, using an in-network provider will save you money.
Annual/Benefit Year Maximum – This is the maximum amount that a plan will pay for care expenses incurred during a specified period – calendar year or benefit year. This amount varies by plan.
Deductible – This is the amount that you are responsible for paying for covered dental expenses before the insurance carrier pays the plan’s benefits. Many plans have a yearly deductible per person up to a maximum amount. Depending on your plan, the deductible may or may not apply to preventive services in Class A.
Coinsurance – Your insurance carrier pays a fixed percentage of a covered dental expense. You are responsible for paying the remaining balance or percentage of the bill.
Dental Plans and Service Classifications
Dental plans will sort covered services and procedures into three or four categories or classifications. Your summary of benefits may express the amount of coverage for in-network services as percentages per each classification. Coinsurance may apply to services and procedures that are not covered by the insurance company at 100%.
Preventive Services (Class A or I) – This category is pretty descriptive, and includes procedures and services that are typically considered routine and preventive or diagnostic in nature, such as routine exams and dental cleanings. Diagnostic procedures, such as x-rays, are other common preventive services filed in this category.
Basic Services (Class B or II) – This category of dental procedures and services typically includes simple restorative services (fillings) and simple extractions.
Major Services (Class C or III) – A major services category often includes more complex dental procedures and services, such as bridges, crowns, dentures, oral surgery or root canals.
Remember that not all dental plans were created equally. Benefit maximums, dental plan categories and deductibles can vary per plan and by carrier. It is up to you to review each plan carefully to decipher if it meets your healthcare and budget needs.
Contact us to learn more about the right dental insurance for you.
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