Insurance: we get it, it can be an intimidating word and a confusing concept. Especially because dental insurance doesn’t function like other types of insurance. Basically, a traditional insurance plan is designed so that it is set up to cover a loss where the insurer carries the risk. Dental coverage, however, is typically set up as more of a benefits plan in that it will cover certain costs up to a determined maximum amount. In fact, the majority of dental plans are based on care delivered and services provided within a calendar year; i.e. what you don’t use, you lose.
Let’s take a closer look at what you need to know when it comes to your dental insurance plan:
What DOES dental insurance cover?
As noted above, dental benefits typically cover certain services provided within a calendar year. This often means bi-annual cleanings and dental exams, or preventive dentistry services. It’s important to understand what is covered by your benefits when you invest in a dental insurance plan, and part of that means familiarizing yourself with industry terminology.
Here’s a quick glossary of terms:
- Annual Maximums: As mentioned, your dental plan will likely only pay up to a certain amount each year. This means that if you have dental expenses of $1,500 in a plan year, but your plan covers $1,000, then you would be responsible for the $500 difference. This is also after you had paid for any deductible.
- Co-Insurance: This term refers to the percentage of charges that you’re obligated to pay. So, if you have a 70/30 plan, then your insurer would pay 70% of the charges and you’d pay the other 30%.
- Deductibles: A deductible is the amount that you’re required to pay before your insurance plan starts to pay. Most dental insurance plans do not require that you meet a deductible for any preventive or diagnostic services, but you’ll want to verify this with your own plan as each can differ.
Dental benefits plans typically require you or your provider to submit a treatment plan for prior authorization before any special services are completed. It’s always a good idea to run your procedure inquiries by your plan’s administrator to gain insight into the treatment proposal & patient eligibility, to assess the co-payment that will be required, and to understand the maximum amount that will be covered.
What types of dental insurance plans are available?
Most insurance plans are acronyms, and they can be difficult to decipher from one another. Here’s a look at the more common dental plans available:
- Preferred Provider Organization (PPO): This term probably sounds familiar from your health insurance plan. Simply put, this is a dental plan that uses a network of dentists who have agreed upon set fees for dental services. The number of dental services covered can vary depending upon the plan. If you have a PPO plan and see a dentist out-of-network, then you will most likely incur expensive out-of-pocket costs.
- Dental Health Maintenance Organization (DHMO): A DHMO functions similarly to an HMO. In this plan or organization, a network of dentists is paid a set fee every month to provide covered dental services to you whether you see the dentist or not. In this structure, some services require a co-payment while others are covered at no cost to you. You’ll want to contact your plan provider to find out which services are no cost to you as they can vary from plan to plan.
- Discount Dental Plans: In this structure, the company selling a discount or referral plan contracts with a group of dentists who agree to discount their dental fees. Also known as referral dental plans, discounts are usually applied to all services, including cosmetic dentistry services. You pay for your own treatment at the reduced rate determined by the plan; the plan itself does not pay for any services rendered.
Of course, this is just the tip of the iceberg when it comes to exploring dental insurance, but sometimes a basic overview is all you need. The most important thing to remember is that in order to benefit from your dental insurance plan, you actually need to make time to visit your dentist!
Feel free to reach out to us at any time with any dental insurance questions or oral hygiene questions in general. The HDG team is here for YOU!