1) There are MANY different types of policies out there!
There are a lot of options when it comes to Dental Insurance, and what type of policy you or your employer has chosen will affect where you can go and whom you can see. The most common types of dental insurance are:
DHMO (Dental Health Management Organization):This type of policy requires you to stay within your insurance carrier’s contracted network of dentists. While often the most affordable, it is also the most limiting of the different policy types.
PPO (Preferred Provider Organization):There are two types of PPOs. Overwhelmingly popular is the variety that allows the patient to see doctors in or out of network with set percentages for each type of provider. There also exist PPO policies that require you to stay inside their network of doctors, though this is less common.
Fee for Service: Often known as Dental Indemnity of Direct Reimbursement plans, this type of plan allows the patient to go in or out of network and pay a specific percentage for each procedure regardless.
Of the above, the Dental PPO is probably the most prevalent. Let’s take a look at what that typically comprises (you’ll see a lot of similarities in break-down here with DHMO and Fee for Service plans).
2) How a Dental PPO policy typically breaks down:
While every policy is different, there are some over-arching similarities in PPO dental insurance policies. Insurance companies will almost always break your coverage down into four major categories:
Preventative: This will include services like cleanings, exams and often xrays.
Basic: You usually see fillings, root canals and periodontal work (dealing with your gums and bone) in this category.
Major: Crowns, bridges, dentures and other extensive work appear here.
Orthodontics: Insurance carriers may add orthodontic coverage to their policies, though often when they do it is limited to children. This varies WIDELY, so if it’s something you are interested in pursuing, make sure to call your carrier and check what benefits you have!
Each category will be covered at a different percentage by your policy, and may or may not be subject to a deductible. While this varies quite a bit from plan to plan, a typical policy will have:
Preventative: 80 – 100%, deductible does not apply
Basic: 60 – 80%, deductible applies
Major: 40 – 60%, deductible applies
A typical deductible will be between $25 and $100, with an annual maximum benefit of $1000 – $2000.
There are a few other key features of dental insurance that are worth noting when choosing a policy or examining your existing one. They are:
Waiting Periods: Some policies will institute waiting periods, either as a general rule or due to late entry to an existing group policy. These are typically in the 6 - 12 month range and usually only apply to basic or major services.
The Missing Tooth Clause: Plans will either provide benefits for teeth you’ve lost before you had the policy or not. This is called the missing tooth clause. Some plans will put one in effect for only the first year or two that your coverage is in effect, creating a specific kind of waiting period.
Preventive Frequencies: Most plans will limit the number of times you can get preventative services within your benefit year (which may be different from a calendar year!). Typically you’ll see cleanings and exams allowed either twice a year or once every 6 months. These are not the same! One allows the cleanings to be anywhere in the year where the other dictates how far apart they must be. You’ll see a similar situation with xrays, which may need to be separated by anywhere from 1 to 5 years depending on the type. Make sure you and your dentist are paying attention to when these services are performed to get the most out of your benefits!
3) You may have Out of Network Benefits you’re not using!
A lot of people think that the benefits they have only work for them if they stay in network. Not necessarily true! What we see in our office most often is out of network benefits that equally match in network for preventative services, and match or cost only 5 – 10% more for more serious work. Many times the only difference comes in how the insurance companies determine their allowable charge (what they’ll pay for each procedure). When going in-network, allowable charges are based on contracted rates determined by the insurance company. When outside of the network, these charges are based on the Usual, Customary and Reasonable fee (UCR) for the geographical area you are receiving service in. If your dentist bases their charges similarly on what is common in the area, you may see very little difference in these out of network rates.
If you have a fee for service or PPO policy and the dentist you want to see is not in your network, all is not lost. Check with your dentist or with your insurance company directly for the lowdown on what your plan offers; you may have more benefits than you think!