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Traditional dental insurance is often perceived as the best way to pay for
dental expenses. And while dental insurance is an excellent option when
sponsored by your employer, it may not be very cost effective when you are
paying for it.
Most individual dental insurance plans require you to satisfy waiting
periods and deductibles before having major and sometimes even minor
restorative work done. Discount dental plans help make maintaining good
oral health a lot more affordable. And, with no waiting periods or
complicated coverage procedures, dental discount plans are about as simple
as you can get.
How do discount dental
plans work?
As we become aware about our oral health,
there has been a demand for affordable dental care. Discount dental plans
are the newest option for those without coverage. These dental discount
plans are much cheaper than traditional dental insurance, and also offer
almost equal coverage for all dental work, even cosmetic procedures not
covered by standard indemnity dental plans.
The catch is that dental discount plans are not really insurance at all.
They work more like club memberships, where the cost of membership (your
"premium") earns a steep discount on any club service (dental work) you
buy. The discount normally applies to all dental office services performed
by an approved "plan" dentist, but no procedure is covered completely.
What are
the ins and outs of discount dental plans? When it comes to dental
discount plans, the good news is afford ability, breadth of services, and
immediate coverage. The bad news is greater financial risk and
responsibility on your part.
Although
the monthly cost of most discount dental plans is very low compared to the
price of a traditional dental insurance or indemnity insurance policy,
there's more allover financial risk with a dental discount plan. No care
is totally covered, so an expensive procedure will mean a big
out-of-pocket expense, even with the dental plan. And even when undergoing
a low-cost service (like cleaning), you'll still be expected to pick up a
part of the cost.
However,
on the plus side, discount dental plans are effective immediately - so are
many procedures you need now will be covered as soon as you buy the dental
discount plan. Traditional indemnity and/or insurance dental plans usually
impose a waiting period of between 6 and 18 months for any major
procedure. The last "pro" is that all good dental discount plans should
come with a money-back guarantee.
Indemnity Plans
This type of dental plan
pays the dental office (dentist) on a traditional fee-for-service basis. A
monthly premium is paid by the client and/or the employer to an insurance
company, which then reimburses the dental office (dentist) for the
services rendered. An insurance company usually pays between 50% - 80% of
the dental office (dentist) fees for a covered procedures; the remaining
20% - 50% is paid by the client.
These plans often have a
pre-determined or set deductible amount which varies from plan to plan.
Indemnity plans also can limit the amount of services covered within a
given year and pay the dentist based on a variety of fee schedules. Some
typical features of these plans:
-
High
deductibles before coverage begins (well-designed plans don't apply the
deductible to preventive services)
-
Probationary periods on certain procedures that last up to a year
-
Annual
dollar limit on benefits
-
Chose
your own dentist
-
Your
average monthly cost: $15 to $25
-
Companies selling these plans are regulated by state insurance
departments.
Dental
HMOs
These
insurance plans, also known as "capitation plans," operate like their
medical HMO cousins. This type of dental plan provides a comprehensive
dental care to enrolled patients through designated provider office
(dentist). A Dental Health Maintenance Organization (DHMO) is a common
example of a capitation plan. The dentist is paid on a per capita (per
person) basis rather than for actual treatment provided.
Participating dentists
receive a fixes monthly fee based on the number of patients assigned to
the office. In addition to premiums, client co-payments may be required
for each visit. Some typical features of these plans:
-
Monthly
premiums (some require you to prepay a year's worth)
-
Co-payments for office visits
-
Free
preventive or routine care
-
You
must select from an approved network of dentists
-
May
have an initial enrollment fee
-
Annual
dollar cap
-
Your
average monthly cost: $5 to $15
-
Companies selling these plans are regulated by state insurance
departments.
Preferred Provider Organizations
Another
true insurance plan, a Preferred provider organizations ( PPO) falls
somewhere between an indemnity plan and a dental HMO. This plan allows a
particular group of patients to receive dental care from a defined panel
of dentists. The participating dentist agrees to charge less than usual
fees to this specific patient base, providing savings for the plan
purchaser.
If the patient chooses to see a dentist who is not designated
as a "preferred provider," that patient may be required to pay a greater
share of the fee-for-service. A group of dentists agrees to provide
services at a deeply discounted rate, giving you substantial savings — as
long as you stay in their network. Unlike the more restrictive DHMO,
though, you can go out of network and still receive some benefits. Some
typical features of these plans:
-
Monthly
premiums
-
Annual
dollar cap
-
You
must stay within the approved network of dentists or pay higher
deductibles and co-payments
-
Your
average monthly cost: $20-25
-
Companies selling these plans are regulated by state insurance
departments.
Dental
Discount
This type of dental plan
is not insurance. The managing organizations have negotiated with local
dental offices to establish a set price for a particular dental procedure
and offer deep discounts (some up to 70%) off the regular ADA pricing
code.
This plan has several
advantages over traditional dental insurance plans, namely, there are no
exclusions for pre-existing conditions. This allows a patient to receive
immediate coverage for work without meeting any waiting period
requirements.
Direct
Reimbursement Plans
A dental
care plan now coming into vogue is the direct reimbursement plan. This is
a self-funded benefit plan — not insurance — in which an employer pays for
dental care with its own funds, rather than paying premiums to an
insurance company or third-party administrator.
You, the patient, pay the
full amount directly to the dentist, then get a receipt detailing services
rendered and the cost, which you show to your employer. The employer
reimburses you for part or all of the dental costs, depending on your
specific benefits.
Your company might reimburse 100 percent of your first $100 of dental
expenses and then 80 percent of the next $500, and 50 percent of the next
$2,000, with a total annual maximum benefit of $1,500. Or it might
reimburse only 50 percent of your first $1,000, resulting in a $500 yearly
cap.
Some typical features of a direct reimbursement plan:
-
Neither
you nor your employer pay monthly premiums
-
Freedom
to choose any dentist
-
Typical
employer cost: depends on the number of employees and benefit
caps
-
Benefits usually capped at $500 to $2,000 annually.
Dental care is quite
different than medical care. Major illness can strike at any time and
the costs can be enormous. Most dental disease is preventable and
treatment is predictable. Regular checkups and professional cleaning
can help maintain your oral health and so dental benefits are written
to encourage patients to seek preventative care in order to prevent
more serious dental problems.
What do you
look for in choosing a plan?
Does the plan
give you the freedom to choose your own dentist or are you restricted to a
panel of dentists selected by the insurance company?
If you have a family dentist with whom you are satisfied, consider the
effects changing dentists will have on the quality or quantity of care you
receive. Because regular visits to the dentist reduce the likelihood of
developing serious dental disease, it's best to have and maintain an
established relationship with a dentist you trust
Who controls treatment
decisions--you and your dentist or the dental plan? Many plans
require dentists to follow treatment plans that rely on a Least Expensive
Alternative Treatment (LEAT) approach. If there are multiple treatment
options for a specific condition, the plan will pay for the less expensive
treatment option.
If you choose a treatment
option that may better suit your individual needs and your long-term oral
health, you will be responsible for paying the difference in costs. It's
important to know who makes the treatment decisions under your plan. These
cost control measures may have an impact on the quality of care you'll
receive.
Does the plan cover
diagnostic, preventive and emergency services? If so, to what extent? Most dental plans
provide coverage for selected diagnostic services, preventive care and
emergency treatment that are basic for maintaining good oral health.
But
the extent or frequency of the services covered by some plans may be
limited. Depending upon your individual oral health needs, you may be
required to pay the dentist directly for a portion of this basic care.
Find out how much treatment is allowed in any given year without cost to
you, and how much you will have to pay for yourself.
-
Initial Oral
Examination----once per dentist
-
Recall
Examinations----twice per year
-
Complete x-ray
survey----once every three years
-
Cavity-detecting
bite-wing x-rays----once per year
-
Prophylaxis or
teeth cleaning----twice per year
-
Topical Fluoride
treatment----twice per year
-
Sealants----for
those under age 18
What routine
corrective treatment is covered by the dental plan? What share of the
costs will be yours? While preventive care
lessens the risk of serious dental disease, additional treatment may
be required to ensure optimal health. A broad range of treatment can
be defined as routine. Most plans cover 70 percent to 80 percent of
such treatment. Patients are responsible for the remaining costs.
Examples of routine care include:
-
Restorative
care - amalgam and composite resin
fillings and stainless steel crowns on primary teeth
-
Endodontics
- treatment of root canals and removal of tooth nerves
-
Oral Surgery
- tooth removal (not including bony impaction) and minor surgical
procedures such as tissue biopsy and drainage of minor oral
infections.
-
Periodontics
- treatment of uncomplicated periodontal disease including scaling,
root planning and management of acute infections or lesions
-
Prosthodontics--repair and/or relining
or reseating of existing dentures and bridges.
What major dental care is
covered by the plan? What percentage of these costs will you be required
to pay? Since dental benefits encourage you to get preventive care, which
often eliminates the need for major dental work, most plans are not
generous when it comes to paying for major dental work, most plans cover
less than 50 percent of the cost of major treatment.
Most plans limit the
benefits--both in number of procedures and dollar amount--that are covered
in a given year. Be aware of these restrictions when choosing your plan
and as you and your dentist develop treatment best suited for you. Major
dental care includes:
-
Restorative
care--gold restorations and individual
crowns
-
Oral Surgery--removal
of impacted teeth and complex oral surgery procedures.
-
Periodontics--treatment
of complicated periodontal disease requiring surgery involving
bones, underlying tissues or bone grafts.
-
Orthodontics--treatment
including retainers, braces and/or diagnostic materials.
-
Dental
Implants--either surgical placement or
restoration
-
Prosthodontics--fixed bridges, partial
dentures and removable or fixed dentures.
Will the plan
allow referrals to specialists? Will my dentist and I be able to
choose the specialist? Some plans limit
referrals to specialists. Your dentist may be required to refer you to
a limited selection of specialists who have contracted with the plan's
third party. You also may be required to get permission from the plan
administrator before being referred to a specialist. If you choose a
plan with these limitations, make sure qualified specialists are
available in your area. Look for a plan with a broad selection of
different types of specialists.
If you have children, you may prefer a
plan that allows a pediatric dentist to be your child's primary care
dentist. Since specialized treatment is generally more costly than
routine care, some plans discourage the use of specialists. While many
general practitioners are qualified to perform some specialized
services, complex procedures often require the skills of a dentist
with special training. Discuss the options with your dentist before
deciding who is best qualified to deliver treatment.
Can you see the dentist
when you need to, and schedule appointment times convenient for you?
Dentists participating in closed panel or capitation plans may have select
hours to see plan patients. They may schedule appointments for these
patients on given days, or at specified hours of the day, restricting your
access.
Some dentist's fees for
seeing you on weekends or during emergencies are high than those the plan
allows. You may be required to pay additional costs yourself. If you
select these types of plans, have a clear understanding of your dentist's
policies as well as the plan's dentist-to-patient ratio. It's the best way
to ensure your access to care is not unduly restricted and that you are
not surprised by higher fees the plan does not cover.
Insurance companies do their best to ensure that their policyholders
understand their plans and benefits, but it is up to an individual to
make sure that they are making informed choices. The
differences in the various plans you can choose from are:
-
The
type of third party funding the plan.
-
Methods of selecting a dentist.
-
Compensation of the dentist's services to you.
-
The
calculations of benefits and payments.
Understanding these differences will enable you to make an informed
decision when selecting a dental plan that is best for you or your
family.
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