What Is Dental Insurance?

Dental insurance helps consumers pay for the cost of dental care. Similar to health insurance, dental typically pays for part or most of dental examinations, cleanings, and other procedures. The type of services that are covered and the amount that is covered for each of those services varies depending on the type of plan and the plan provider.

This type of insurance may be available through your employer or another group such as a union which is referred to as group insurance. You may purchase your own policy directly through a provider which is known as individual insurance. There are many different dental plans, and they all cover and do not cover different things, so it is important to carefully examine all of the available options so you can find the plan that is right for you.

Dental plans are available for various types of dental work. Some plans will cover all of these types of services, while other plans may only cover some services. Different plans will cover the same service at different rates, so there is a lot to consider. First, you should understand the different types of dental care.

• Preventative dental care includes those services that are designed to prevent, not correct, dental problems. Preventative services include cleanings (usually annually or semi-annually) and examinations. X-rays, sealants, and fluoride may also be considered preventative services.
• Restorative dental services, sometimes called Basic services, include things like fillings and extractions (pulling a tooth). If X-rays, sealants, and fluoride are not covered under preventative care, they will be covered under Basic care. Some plans consider more complicated procedures such as root canals to be restorative, while others consider them to be major services.
• Major dental care procedures include things like dentures, partial appliances, bridges, crowns, dental implants, and surgical extractions. If root canals are not covered under Restorative care, they will likely be covered under Major care.
• Orthodontic services include braces, retainers, and other devices that are used to straighten teeth. If you have children, it often makes sense to choose a dental plan that includes orthodontic care. Most plans do not cover orthodontic care in full, but will pay part of the total expense.
• Cosmetic dental procedures include things like caps (if they are put on for the purpose of making the teeth look better as opposed to a medical reason) and whitening. Most dental plans do not cover cosmetic procedures.

While it can be difficult to predict what type of dental care you may need in the future, you may be able to make an educated guess about certain things. For example, if your children are adults, you probably do not need a plan that includes orthodontia. If you are in your sixties or seventies, it may make sense to choose a plan that covers dental appliances like dentures and bridges.

There are three major types of dental insurance plans.

• A Fee-for-Service plan (usually only available as group insurance) sets a fee for each type of dental service. The plan determines what they consider to be a ‘reasonable and customary’ amount for each type of dental service. A Fee-for-Service plan uses direct reimbursement, which means that you can go to any dentist you choose, pay the bill, and then submit the claim to the insurance company. The insurance company reimburses you for the ‘reasonable and customary’ rate for that service, minus any co-payment or deductible. The remaining cost, if any, is your responsibility. This type of plan is sometimes referred to as a Dental Indemnity Plan.
• A Managed Care Plan gives you an incentive to go to a provider in their network by covering more of the cost of work done by network providers. If you go to a dentist outside the network, your dental work may be covered at a lower rate or not at all.
  

A managed care plan can be a PPO (Preferred Provider Organization) or an HMO (Health Maintenance Organization). In a PPO, the participating dentists agree to a fee schedule set by the insurance company. The insurance company refers patients to the dentists in the network, assuring them a steady flow of patients. In an HMO, the dentist is paid a set fee by the insurance plan and agrees to provide required services to those insured by the plan.

• The third type of plan is actually not an insurance plan, but a discount plan. For this service, you pay an annual membership fee (as opposed to the premium that you pay for insurance) and you get discounted dental care from providers who accept your discount card. Discounts will vary by procedure and can range from 10 to 60 percent.

A good plan can drastically reduce the amount of money you have to pay for dental care for yourself and your family. Educate yourself and choose wisely.

Understanding the Policy

A dental insurance policy is a contract between you (sometimes referred to as ‘the subscriber’) and the insurance company (‘the insurer’). Understanding what is contained in the policy and what it means can help you choose the best policy for your needs and get the most benefit from your policy once you have enrolled in it.

Generally, a dental policy will detail several things: the amount of premium you have to pay, the deductible you will have to pay before the insurance begins to cover any costs, any co-payments that you will have to make, and which dental procedures and services are covered. It may also describe which types of providers you can use in order to receive benefits under the policy.

The premium is the amount you have to pay to the insurance company in order to retain the insurance plan. If your employer provides the plan under a group coverage arrangement, the premium may be deducted from your paycheck. You employer may subsidize part of the cost as an employee benefit. If you purchase an individual plan directly from an insurance company, you will have to pay the premium directly to the company. Most companies offer a monthly payment plan. Make sure that you pay your premium on time, or the insurance company can cancel your coverage.

The policy will also indicate the amount, if any, of your deductible. Some plans require you to pay a certain amount of the cost of your dental work before the insurance company begins to pay. The deductible will be expressed as a dollar amount and may apply to each individual on the policy or to the entire family, if the policy is a family plan. Once you have paid the cumulative deductible amount, your insurance will then pay claims in accordance with the contract.

A co-payment is your contribution to each dental visit or procedure. When you go to the dentist, you will pay the co-payment. The dentist then submits the claim to the insurance company, which pays the dentist directly. The co-payment may be a fixed dollar amount or a percentage, or some combination of both.

Most dental plans will have a deductible or a co-payment, but not both. Fee for service or indemnity plans tend to have a deductible, while managed care plans often have a co-payment.

A dental policy will include a list of covered services, usually grouped into categories. The plan will indicate which services it considers:

• Preventative, which usually includes examinations and cleanings, and sometimes includes x-rays, fillings and sealants.
• Restorative, which includes fillings and extractions. This category also includes x-rays, fillings and sealants if they are not considered preventative. Some plans consider crowns and root canals to be restorative, while others group them under Major procedures. Sometimes restorative procedures are called Basic procedures.
• Major, which includes crowns and root canals if not considered restorative, as well as appliances (dentures, bridges, etc.), crowns, implants, and surgical extractions.

Most plans cover Preventative services at or near 100% to encourage patients to get regular preventative care. Regular preventative care tends to reduce the need for more complicated and costly procedures in the future. Restorative services are usually covered at a percentage, with Major services covered at a smaller percentage.

Orthodontic services and cosmetic dentistry are not covered under most policies. Policies that cover orthodontia will specify that in the policy. In those policies that include it, orthodontia is usually covered at 50% with a maximum per year and/or per person.

Your policy may specify different levels of coverage for in-network and out-of-network dentists. The names of dentists in a given plan’s network can usually be found on the plan provider’s web site.