Since it’s ACA open enrollment time, and dental plans are being offered (but not required), I thought it might be helpful to detail out some information in regards to dental insurance. This may be far reaching, but if you are thinking of purchasing dental Insurance, or have questions about your own insurance, I hope you find this information helpful. (For the record, I have been working in dental offices for the better part of 30 years, the last 10 billing (and fighting) insurance companies.)
First and foremost: Stop thinking about dental insurance as “Insurance”. It’s not. It’s really a gift card that can be used for certain purchases for certain amounts. The trick, as a consumer, is to figure out if you are going to spend more money on the gift card than you will actually use.
Second: The information I’m providing should be useful for both people who have dental through an employer, and for people purchasing individual dental. Because there are many specific things to know about individual plans, I will detail that out towards the end of the article, so feel free to skip ahead if this is TLDR.
*Important information before we begin!
1) Everything I’m saying is very general. Individual insurance plans may vary widely from the examples I give. They get to set maximums (the amount the insurance company pays out for a year) , deductibles (the amount you have to pay before the insurance kicks in), frequencies (how often they will pay for specific services), and exclusions (what they won’t cover).
2) Every dental office has a fee schedule. That is the list of fees that are charge for services. Most insurance companies also have a fee schedule, a common verbiage is “Usual and Customary fees” (we’ll abbreviate to “U&C”). What that really means is “We are going to pay $X.00 for that procedure”.
3) Dental plans break out services by category. In general, these are:
Preventative and diagnostic : Preventative cleanings, fluoride, sealents, exams, x-rays, sometimes periodontal maintenance cleanings
Basic: Fillings, root canals, extractions, periodontal treatment
Major: Crowns, bridges, dentures, implants
Every plan gets to decide what is included in their categories, so while the above list is the norm, it’s not always the case. Most self purchased plans put root canals, extractions, and periodontal treatment in the Major category. There are also exclusions, meaning there are things that are simply not paid for. Common exclusions are night guards, implants, or replacing any teeth missing before you came on the plan. Finally, there can be “downgrades”, meaning the insurance may approve a procedure, but pay for a less expensive procedure (Example: You have a tooth colored filling on a back tooth. Your insurance pays what it would pay for silver, leaving you with the difference in cost).
4) I am ONLY discussing traditional employer or individual purchased insurance, NOT dental insurance paid as a medical rider, or ACA children’s dental that’s part of a medical rider, or dental insurance that’s purchased as part of a Medicare supplement policy, or discount plans…..that would require a separate post!
There are 3 kinds of insurance plans out there:
1) Fee for Service This type of plan allows you go to any dentist. The dentist will bill the insurance, and the dentist will get paid, however there might be an option for you to pay your dentist and then be reimbursed. There are no networks. The dentist will bill the insurance their regular fees. The insurance will pay the dentist based on the insurance company fee schedule, which frequently, but not always, aligns with the dental office fee schedule. There are not “Co-pays” with this type of plan, meaning there isn’t a set dollar amount you pay at each visit. Instead, the insurance pays a percentage of the treatment cost. A typical breakout would be: Preventative services are paid at 100% (so you, the patient pays nothing additional out of pocket), basic services are paid at 80%, major services are paid at 50%. There is yearly Maximum amount that the insurance will pay (average is $1000-1500), and normally there is a yearly deductible ($25-75). The deductible usually applies to treatment only (fillings, crowns, etc), not to preventative and diagnostic treatment. With this type of plan, if your dentist bills the insurance company for a service, and if the insurance U&C is less than what the dentist billed, you are responsible for the difference. (Example, your dentist bills $1100 for a crown, the U&C is $1000, you will be billed an additional $50 after the insurance pays their percentage).
2) PPO, or “Prefered Provider Organization” These plans are very similar to Fee for Service, with one really big exception. They have a network of dentists who have agreed to accept the insurance company fee schedule in place of the dentist’s own fee schedule. This results in fees that are 10-50% less than the dentist’s full fees. (Example: The dentist’s fee for a crown in $1000, the PPO fee schedule is $800. Your 50% co-pay is now $600 instead of $500). Most (but not all) of these plans will still pay even if you go “out of network”, but it can mean you will be paying more out of pocket for the difference between the PPO fees and your dentist’s fees. In addition, some PPO plans waive the deductible if you go in-network, or provide a higher level of reimbursement (Example: If you go in-network, preventative treatment is paid at 100%, if you go out of network, it’s paid at 80%). Usually, if the dentist is in-network, he HAS to bill and receive the payment.
3) DMO, or “Dental Maintenance Organization” With this type of plan, you can ONLY go the dentist or clinic that you have been assigned to. If you go anywhere else, there are no benefits. These plans do NOT work on a percentage payment basis, this is the one plan that works on “Co-Pay”, meaning you have a set dollar amount for whatever service you are having performed. If you are on your states Medicaid system, this is the type of dental plan that you have. The dental office, instead of being paid per procedure, is paid a flat amount monthly for every patient assigned to them. (Example: if Pretend Dental has 1000 patients assigned to them from DMO Insurance, and DMO Insurance pays $15.00 per patient, Pretend Dental receives payment of $15,000 every month). You, as a patient, may pay nothing in addition for cleanings, $20-50 for fillings, $150-350 for crowns.
What type of plan is right for you? Let me lay out the advantages and disadvantages of each:
Fee for Service: Advantages: You can see anyone you choose. The reimbursement rate for procedures is the highest. Disadvantages: Your out of pocket costs will usually be higher than with any other type of insurance. You may have additional money owing after insurance pays if the insurance paid fees and the dentists billed fees don’t line up. *TIP: If you are concerned about knowing exactly what you will be paying, ask your provider to preauthorize the treatment before you begin! It may mean you have to with 1-4 weeks, but you will know exactly what the insurance will pay for.
PPO: Advantages: Usually you can still see anyone you choose, but you will save money if you see a provider in-network. They cost less to purchase, and your out of pocket expenses are less. Disadvantages: Your dentist whom you love might not be in-network.
DMO: Advantages: Least costly of all the options, both in premium and copays. Disadvantages: The service you will receive will be much less than either of the other two options. Usually, the only offices that take DMO insurance are large corporate clinics. *By the nature of how they are paid it is in the clinics best interest to see or treat as few patients as possible in order to make money. They do this by limiting the amount of time you are seen (15 minutes for a cleaning instead of an hour), limiting the amount of treatment you can receive at each visit (1 filling instead of the 4 that are in the same area), and only offering the least costly option for services (a single tooth partial instead of an implant or fixed bridge). In fairness to the DMO clinics, some of this is mandated by the insurance company.
Specific information about self purchased individual plans: As with ALL dental insurance, there are really no “Rules”, BUT, here are the two things you need to take into account when figuring out if purchasing a plan is a financially prudent decision:
1) Waiting periods: If you are purchasing your own insurance, there will be waiting periods involved. The most common is a 6 month wait for fillings (usually pays for preventative cleanings/exams right away, although I’ve seen 3 month waits for that), and 12 month wait for ANY other treatment. *TIP: With many self purchased plans, IF you can show a uninterrupted history of having dental insurance, they will waive or adjust the waiting periods. *There can be waiting periods on employer sponsored plans as well, but they tend to be the exception as opposed to the rule.
2) Most plans consider things like root canals, periodontal treatment, and extractions to be major treatment, which is different from most employer plans (they pay at a lower percentage).
“Is purchasing insurance right for me?” Here’s what you need to do to figure it out. Call up your dental office. Ask what a year’s worth of maintenance visit’s cost. Do you have any work that’s needed? What is it, and what is the cost. Does your dental office offer any cost savings for patients paying cash (more offices are offering “in house” dental plans)? Add up the costs of yearly maintenance, then factor in what the treatment cost is, and subtract any savings you might be offered by your dentist. THEN, look at the plan that you are considering purchasing. What is the yearly premium? Is your dentist in the network? If yes, ask the dental office what the fees are if you are going to be in that network. What will your out of pocket cost be on work that needed, making sure to take into account what you will pay in deductibles and the maximum plan payment (provided, of course, the work can wait until any waiting periods are met….that may not be advisable). Add that up. Compare the two. That will tell you if purchasing a plan is worth it or not. If you do not currently have a dentist, and you’re being offered a PPO plan, visit an office or 3 that are on the list. Ask them the same questions. If they don’t have time for you or can’t (or won’t) give you answers...move on to the next one on the list.
Ok, have to get ready for work. I hope this is clear and in some way helpful to you. I am more than happy to answer any questions, but I won’t be back until 7ish pacific time…. Job and workout, don’tcha know. If you’re ok with a delayed answer, ask away!!
Edit: Wow, rescued community spotlight? Awesome! Again, really hope the info is helpful!