Dental insurance can be a confusing field to navigate. Even those of us that work with it daily can get confused with the changes and the different plans and coverage offered. Here is a breakdown of the different coverages that can be offered. In no way is this an endorsement or recommendation of any dental insurance. This is just offered to help the lay person understand how their particular benefits better. Specific questions are best directed to your insurance company customer representatives.
Let’s start at the beginning:
The history of dental insurance does not go back very far. The first dental insurance plans started in the late 1950's and did not get popular until the late 1960's. Unfortunately though, the benefits of the average dental insurance plan have not changed since the 1970's. Think about that. The dental insurance plan one had in the 1970's, which had about a $1,000 max on benefits, has the same benefit max as a dental insurance plan one can buy today, about $1,000. Now consider how much more dental insurance costs are now compared to the 1970's. With all the technology currently incorporated into one's dental care, it is obvious to see why many view dental insurance as an optional insurance choice.
Moving into the present, here are some dental insurances, and how they work. They may be offered by an employer, a group, or targeted to individuals.
HMO stands for Health Maintenance Organization
Dental HMO- a true dental “plan”. There are no maximums and no deductibles. You can have $5.00-$5000 worth of dental work done and it’s all covered at a reduced fee. There is no filing and no paperwork. How this plan works is that you choose or are assigned to a participating provider. Lists of participating providers are given to you when you sign up. YOU MUST SEE THAT PROVIDER TO GET YOUR DENTAL BENEFITS. You are not allowed to go out of network. If you go out of network, your dental benefits do not apply. Any services not listed will be given to you at a discount. If you need to go see a specialist, you usually need to be referred by your participating dentist to get your dental benefit. If the protocol is not followed-then you may be responsible for the full fee for the service done.
HMO pros: No paperwork or filing. No maximum or deductible.
HMO cons: Must go to assigned provider to get benefit. If you do not like the provider you see-too bad. You can request a change to another participating provider, but you must go through the insurance company to do so, and it is not always immediate. If your dentist that you have used forever and love isn’t a participating provider, that’s too bad too. You have to choose from the list and be assigned there if you want to use your benefits.
PPO stands for Preferred Provider Organization
Dental PPO-More like a traditional insurance, in that it has a yearly plan maximum and deductible. Benefits renew every calendar year or plan year. Services are grouped into categories. Preventative, Basic, and Major. The categories are each covered at a percentage. With a PPO-you may go to a participating provider or a non-participating provider. Participating providers have signed a contract with the insurance company agreeing to accept reduced fees for the services. The reduced fees are agreed upon by the dentist and the insurance company. Non-participating providers are not contracted by the insurance company, so they charge their usual and customary fees. The insurance company encourages members to go to participating providers by offering the reduced fees. If you go to a non-participating provider, and the fee is more than the insurance company allows, then you are responsible for the difference in cost. However, in many instances, the non-participating provider’s fee for service may be within what the insurance company allows, so the out of pocket cost to the individual may be the same.
PPO pros: Members can go in or out of network for services. They may receive a better benefit if seeing an in network dentist.
PPO cons: If going to an out-of network provider, members may be responsible for cost difference in what the insurance company allows for the services, versus usual, reasonable and customary fees of the non-participating provider. Also, if going to an out-of-network provider, some insurance companies will not accept assignment. What this means is, that even though the dentist may file the claim for you, the insurance company will not pay the dentist-they will mail the payment to the patient. That leaves the patient responsible for the full cost until the insurance company mails the patient the payment.
Indemnity Dental Insurance: This is the traditional insurance. There is a yearly maximum and deductible. Benefits renew every calendar year or plan year. You can go to any dentist, and they pay percentages of the three categories: preventative, basic, and major.
As I stated initially, the dental insurance field is tricky to navigate and understand. The front desk staff is ready to help you if you have any questions, or contact your insurance representative.
Here's to a healthy and happy 2015!
Dr. Rachel Beyer and Staff