According to the National Association of Dental Plans, the majority of Americans (77%) have dental benefits, with private coverage being the most common, often provided by employers or group programs. Dental benefits are more commonly offered by larger employers and received by high-wage workers compared to low-wage workers.
To make the most of your benefits, read below for a few things that you should understand about dental insurance.
Dental Plan Categories
Although the features of the plan may differ, the most common dental plans can be grouped into the following categories:
- Direct Reimbursement Programs
Under direct reimbursement programs, patients are reimbursed a fixed percentage of their total dental care expenses, regardless of the treatment type. This approach usually does not limit coverage based on the required treatment, enables patients to select their preferred dentist, and motivates them to collaborate with their dentist to achieve healthy and financially viable outcomes.
- Usual, Customary, and Reasonable (UCR) Programs
With Usual, Customary, and Reasonable (UCR) programs, patients usually have the freedom to choose their dentist. These plans provide coverage for a fixed percentage of the dentist’s fee, or the “customary” or “reasonable” fee limit set by the plan administrator, whichever amount is lower. The fee limits are established through an agreement between the purchaser of the plan and the third-party payer. Despite being referred to as “customary,” these limits may not necessarily reflect the actual fees charged by dentists in a particular area, as there is a significant variation in how plans determine the “customary” fee level, and no government regulation exists to standardize this process.
- Table or Schedule of Allowance Programs
Under Table or Schedule of Allowance programs, a predetermined list of covered services with designated dollar amounts is established. These amounts indicate the extent to which the plan covers the listed services, irrespective of the actual fees charged by the dentist. Any difference between the allowed charge and the dentist’s fee is invoiced to the patient.
- Capitation Programs
Capitation programs compensate contracted dentists with a predetermined amount per enrolled patient or family, usually paid monthly. In exchange, dentists commit to providing certain types of treatment to patients at no cost, although there may be a patient co-payment for some treatments. The capitation premium paid to the dentist may significantly vary from the actual amount provided by the plan for the patient’s dental care.
Types of Dental Plans
Dental plans share some similarities with health insurance plans, but also differ in several aspects. Typically, you will have the following choices:
- Preferred Provider Organization (PPO): Like a health insurance PPO, these plans have a network of dentists who accept the plan. While you can choose to visit an out-of-network dentist, your out-of-pocket expenses will be greater.
- Dental Health Maintenance Organization (DHMO): Similar to a health insurance HMO, these plans offer a group of dentists who accept the plan for a predetermined co-payment or no fee at all. Nonetheless, seeing an out-of-network dentist may not be feasible.
- Discount or Referral Dental Plan: In this type of plan, you receive a reduced price for dental services from a particular set of dentists. Unlike health insurance, the discount or referral plan does not cover any expenses for your care. Instead, the participating dentists offer a discounted rate for the services you receive.
Understanding Dental Insurance Plans
Predetermination of Costs
Certain dental insurance plans may encourage you or your dentist to submit a treatment proposal to the plan administrator beforehand. The administrator will then assess your eligibility, the duration of your eligibility, the covered services, your co-payment, and the maximum limit. For treatments that exceed a specific dollar amount, some plans mandate obtaining predetermination. This process is referred to as preauthorization, precertification, pretreatment review, or prior authorization.
Annual Benefits Limitations
In order to control expenses, your dental insurance plan may restrict benefits based on the number of procedures or dollar amount in a given year. In many instances, particularly if you’ve been receiving regular preventive care, these limitations offer adequate coverage. By being aware of what procedures and amounts the plan permits, you and your dentist can strategize treatment to reduce out-of-pocket expenses and maximize the benefits offered by your plan.
What Dental Plans Cover
In general, dental policies provide coverage for a certain portion of the expense of preventive care, fillings, crowns, root canals, and oral surgery, such as tooth extractions. They may also cover orthodontics, periodontics (the tissues that support and surround the teeth), and prosthodontics, such as dentures and bridges. Typically, you are eligible for coverage for up to two preventive visits per year.
When you purchase an individual dental policy, it’s important to note that coverage for periodontics and prosthodontics may not be available in the first year. Additionally, coverage for orthodontics may require an additional fee in the form of a rider.
In general, dental plans follow a coverage structure known as 100-80-50, which means they cover preventive care at 100%, basic procedures at 80%, and major procedures at 50% or with a larger co-payment. However, it’s worth noting that some plans may choose not to cover certain procedures, such as sealants, at all.
What to Do Before a Dental Procedure
Carefully review your dental policy to determine whether your procedure is covered. If you have any questions, contact your insurance company. If you require a major procedure, you can request that your dentist submit a pre-treatment estimate. This will give you an idea of what you will likely owe after deductibles, coinsurance, and the policy’s maximum benefits.
It’s also important to understand your dental plan’s approach to emergencies. While many plans have provisions for urgent or after-hours care, you may be responsible for a deductible, copay, or a larger percentage of the costs.
We understand that navigating co-pays, forms, and deductibles can be confusing. That’s why we take care of tracking and filing your insurance claims for you, so you can focus on your dental health. If you have any questions or concerns about your insurance coverage, please don’t hesitate to reach out to our office. Our knowledgeable team members would be happy to assist you in any way we can.
Call us at (630) 530-0770 or contact us at https://elmhurstdentistil.com/contact-us/