Dental insurance is a type of medical coverage that pays for some or all of the cost of certain types of dental care. Many plans have a deductible and an annual maximum for benefits.
Most dental insurance plans offer a list of in-network dentists who have agreed to discount their services. These dentists are called preferred providers.
Cost
Unless subsidized by an employer and covering multiple employees, dental insurance is often not cost-effective for self-paying individuals. The average person without insurance spends about $200 a year on basic care, while a typical dental plan costs $500 or more annually. In addition, most plans have deductibles and annual maximum benefit limits that can make it expensive to cover routine care and major procedures.
Many dental plans also require copayments, which are a set dollar amount that patients must pay before the insurance coverage kicks in. In addition, most dental insurance policies have a yearly maximum that the insurer will pay for care, which typically ranges from $1,200 to $1,500. When selecting a policy, it’s important to consider these expenses as well as the benefits of dental insurance.
For those who are interested in keeping costs low, a Dental Health Maintenance Organization (DHMO) may be the best option. These plans offer lower costs and predictability, as well as limited networks of providers. However, they do not include coverage for out-of-network care.
Another option is a Dental Preferred Provider Organization (DPPO), which provides low-cost coverage for in-network services and a small copayment for out-of-network care. It is important to verify that your preferred dentist or specialist is included in the DPPO network before enrolling in a dental insurance plan.
Benefits
Dental insurance, often available as part of a health care policy or separately on the marketplaces established by the Affordable Care Act (ACA), helps consumers cover the cost of routine examinations, cleanings, and X-rays. These benefits can help consumers save money on these services and encourage them to visit the dentist regularly, catching problems early when they are generally less expensive and easier to treat.
Most plans require that a copayment or deductible be paid on services before the plan begins to pay. The amount of this copayment or deductible varies from plan to plan. In addition, most dental insurance policies include a maximum benefit or cap on the dollar amount of care that the plan will pay in a year, beyond which consumers are responsible for all costs. Some plans also have a separate maximum on orthodontia costs.
Some plans also limit the frequency of certain procedures or exclude certain treatments completely. These restrictions can be frustrating for people who need these treatments, but they are intended to control costs and prevent abuse of the system. Dental insurance policies usually allow a limited number of exceptions to these limitations, depending on the individual’s medical history and the specific needs of the patient. In addition, some plans use a system of determining primary and secondary coverage for dependent children based on the birthday of the parent with primary coverage.
Limitations
Many people wonder whether dental insurance is worth the cost. Unlike other types of insurance, which cover a wide range of issues and allow policyholders to use their benefits to offset costs, most dental plans have strict limitations. For example, some dental policies may only pay for two cleanings per year, while others might not cover certain procedures. In addition, a plan’s deductible and annual limits may also limit coverage.
Those who get their dental insurance through their employer often don’t have to worry about these limitations, because their employers subsidize the monthly premiums and can negotiate lower rates for dentists in the company’s network. However, if you’re purchasing an individual dental insurance policy or adding it to your health insurance as a rider, you should be aware of the limitations associated with each type of plan.
A common limitation of most dental insurance plans is the “usual, customary and reasonable” (UCR) limitation. UCR is the amount that a dentist typically charges for a specific service and is used to determine how much the insurer will pay for the procedure. The problem with this limit is that it can vary widely, making comparisons between plans difficult.
Another limitation of dental insurance is that it only covers preventive care at 100 percent, and basic services like fillings or crowns are generally covered at 80 percent, according to the National Association of Dental Plans. These limitations can make dental insurance unattractive for those who don’t need extensive work, but will still need to spend money on routine cleanings and X-rays.
Dual coverage
Dual coverage happens when a client is enrolled in more than one dental insurance policy. This can happen when two people have employer-provided dental insurance plans that cover their spouses, if children are covered by both parents’ policies, or if a person has government-sponsored coverage such as TRICARE (for military members) and Medicaid. When a person has dual coverage, both insurers will share the cost of the treatment, and they will usually coordinate benefits to ensure that there is no duplication of payments or gaps in coverage.
However, this can be complicated and may require some juggling of payment schedules between the two policies. Also, some secondary insurance policies have “non-duplication of benefits” provisions that prohibit the secondary plan from paying if the primary plan already paid the same amount or more for the same service. This can result in the need to obtain prior authorization from the primary plan for some treatments.
To avoid this confusion, it is important that a person with dual coverage informs their dentist about both of their plans. Ideally, this should be done before receiving any services because it is illegal for someone to receive covered services without informing their dentist of the existence of additional coverage. In addition, a professional dental insurance billing company can help individuals manage their coverage by providing a complete insurance verification service and communicating with both insurance carriers to ensure that the proper information is submitted to each one.