Dental insurance helps individuals afford necessary oral care. While deductibles, copays and waiting periods may apply, most plans include annual benefit maximums.
DHMOs (dental health maintenance organizations) resemble HMOs in that they restrict members to visiting dentists within the insurer’s network. Preferred provider organization plans (PPOs) offer more choice and flexibility.
In-network or out-of-network dentists
As a dentist, being in-network with insurance means your practice will be readily accessible and promoted by the insurer to patients seeking care. This can bring in more patients and help with cash flow. However, being in-network also means you’ll have to agree to fees that are pre-established by the insurance company. This may not be ideal for dental practices that value their independence and freedom to decide how much to charge for their services.
Dental insurance companies keep databases of normal fees for various services in different geographic areas to ensure their allowed charges are consistent and reasonable. In-network dentists abide by these allowed charges, which makes it more likely they will be covered by your insurance.
Choosing an in-network dentist is often a matter of balancing your personal preference, the cost of your monthly premium and the benefits offered by a specific plan. Many dental plans offer lists of in-network providers that can be found online or through annual materials sent to you from the insurance provider. However, it’s important to note that you can still get great coverage from an out-of-network dentist, though you’ll pay more at the time of service and may hit your annual maximum much more quickly.
Deductibles are the amount of money you have to pay before your insurance coverage kicks in. They may be different for each family member’s plan. Once the deductible is met, your insurance company will cover a percentage of the cost of treatments. This percentage is known as coinsurance, and it’s important to understand how it works before going to the dentist.
Most dental plans also have frequency limits, which limit the number of times in a year or a period that your insurance provider will pay for certain services. For example, they may only pay for two cleanings per calendar year or one full series of X-rays every three years.
In addition to deductibles, you should be familiar with other important terms, such as annual and lifetime maximums. The annual maximum is the most your insurance will pay in a benefit period for certain services, such as oral surgery. Some plans also have a lifetime maximum for specific types of treatment, such as orthodontics or TMJ.
Coinsurance is an insurance concept that splits up the cost of a dental procedure between you and your insurer. The coinsurance percentage is usually listed on your plan’s fee schedule. For example, your plan may list that a treatment costs $100, with 80% or 20% being covered by the insurance company and the remainder being your responsibility.
Dental HMO-style plans often require a copay, a fixed amount you pay for a service before your insurance covers the rest. This is a predetermined amount, like $20, that does not change no matter what the dentist charges for the service. Copayments are typically required for non-preventive services and are due even after your deductible is met.
Some other types of dental insurance have no deductible and do not use a fee schedule. These are called indemnity plans and offer more flexibility when choosing a dentist. However, they tend to have higher monthly premiums and annual maximums. They also can have more paperwork. Most indemnity plans do not cover out-of-network care. However, some do cover the “usual customary and reasonable” fees charged by your dentist.
With fall upon us and employee benefits open enrollment fast approaching, it’s important to understand how annual maximums work. A maximum is the amount that an insurance provider will pay toward your dental care costs over a year and typically resets at the beginning of each calendar year.
Your annual maximum will likely be displayed on your plan documents along with the coverage details and limitations. It may also be included in the Detailed Explanation of Benefits (DEB) your insurance company provides after each appointment.
As you make appointments, the cost of each procedure will be tracked and subtracted from your annual maximum. Once you reach the annual maximum, your insurance will stop paying for additional services. When this occurs, you are responsible for 100% of the cost until your next benefit period begins. If you have pending or necessary treatments, it’s a good idea to prioritize them and get them done before your maximum is reached. This will allow you to receive full benefits from your coverage and prevent a large bill down the road.
Dual coverage occurs when a person has more than one dental insurance plan. It can happen when spouses have different employer plans, parents have two dental insurance policies that cover their children, or someone has a group and individual plan.
When this happens, the insurance companies have a coordination of benefits (COB) policy that dictates which plan pays first and how much the secondary plan will pay. The rules vary based on the type of plan, but it is generally true that the secondary policy will only pay up to what the primary plan would have paid had it been the sole primary policy.
It is important for my clients to understand COB and how to make sure they are not double-paying for services. The rules are slightly different for individual versus group plans as well. Typically, the individual plans don’t coordinate with each other, but group plans do. In these situations, the primary carrier is usually the plan provided by the employee’s current or former employer. In addition, the rules may also state that a non-duplication of benefits clause prevents the secondary plan from paying anything after the first insurance has already paid its normal share.