Generally, dental plans have deductibles, copays, and annual maximums. These limits apply separately to each member on the plan. Some dental insurance plans also have waiting periods and/or limited coverage for major procedures.
If you want to stick with your dentist, you can choose a DHMO or a DPPO (or a DEPO, if your dentist is part of one). These plans typically have smaller provider networks.
Coverage
Dental insurance covers a portion of the cost for procedures that improve and maintain oral health. It is typically separate from medical insurance, although many employers include both types of coverage in a single benefit package. When choosing a dental plan, pay attention to monthly premiums and deductibles, as well as maximum annual and lifetime limits on reimbursement. These limits can significantly impact the cost of a procedure.
Most dental plans cover preventive care such as bi-annual cleanings and exams, and some will even cover X-rays. Some also have a limited number of visits per calendar year, while others may have a waiting period before certain treatments can be covered.
Some plans offer a preferred provider network, in which the insurer negotiates fees with a group of dentists. Other plans are open-panel and allow you to choose any licensed dentist, but may not reimburse as much for out-of-network care. Finally, some plans require a predetermination form (also known as prior authorization) for any treatment above a specified dollar amount. This may delay or prevent your treatment, so it’s important to carefully read the terms of your policy.
Deductibles
When shopping for dental insurance, it’s important to understand deductibles and annual maximums. These are the amount that a patient has to pay before the plan’s benefits kick in. They are different from a premium, which is the monthly or yearly payment required to maintain coverage. Deductibles and maximums vary between plans, even those from the same insurer.
Some services are exempt from the deductible, such as diagnostic tests and routine examinations. Others are covered in full, including preventive procedures like teeth cleanings and fluoride treatments. These services are designed to prevent and detect problems early, which helps keep costs down.
Most plans have an annual maximum, which is the amount that the insurance company will pay toward a given treatment in one year. Many also have a lifetime maximum, which is the maximum amount that the insurance will ever pay for a particular service, such as orthodontic treatment. Some plans may also require a waiting period before covering certain types of procedures. Many plans use a table or schedule of allowance to determine how much they will reimburse dentists for specific services, but this varies from plan to plan.
Co-pays
Dental insurance is typically provided by employers, or can be purchased as a “rider” to medical insurance policies. It is important for consumers to understand how different plans work, including their coverage, deductibles and copayments. eHealth offers a free online comparison tool to help individuals find the best dental insurance for their needs.
A deductible is the amount a patient must pay for services before the insurance company starts to cover costs. A co-payment is a flat fee that the insurance company requires patients to pay for visits or treatments, and it usually doesn’t count towards a patient’s deductible.
The best dental insurance plans have a broad network of providers and low deductibles, making them more affordable. However, they may also have higher premiums than other types of dental coverage. For example, a dental PPO plan allows patients to visit any dentist, but may require them to pay more for care that is not in the network. Similarly, a Dental HMO plan has a smaller network and requires that patients stay within the network to receive covered services.
Annual maximums
Most dental insurance plans have annual maximums, which is the amount that your insurance carrier will pay for a dental care procedure within a given year. This limit usually resets on January 1st. It is important to talk to your dentist about this limit when scheduling for care, as he or she may be able to plan treatment around it.
The annual maximum is the yearly limit on the allowed amount that your dental insurance company will pay for services, once you have reached your deductible. Once the annual maximum is reached, you will need to pay for all additional costs. However, there are some plans that do not have an annual maximum, so it is important to check the details of your individual dental insurance plan.
The majority of individuals who have PPO or DPPO dental plans do not reach their annual maximum. To help prevent this from happening, you can schedule non-urgent procedures early in the year and delay them until after the yearly maximum has reset. This way, you can avoid the high cost of unplanned dental work.
Networks
The networks provided by dental insurance can have a huge impact on your cost and coverage. Most plans use networks to provide patients with easy access to a wide range of dentists that accept their plan. This helps reduce paperwork for both the dentist and the insurance company. In addition, it can reduce costs by allowing the insurer to negotiate fees with network dentists.
Insurance companies also provide a list of in-network dentists that have agreed to charge discounted rates. This is referred to as a “negotiated fee schedule.” In-network dentists are usually able to offer services at lower costs than non-in-network dentists.
Indemnity plans typically do not have a network of dentists, and allow you to see any dentist that accepts your plan. However, these plans often have a higher cost and may not cover all types of treatments.
Other types of dental plans are managed care plans, such as HMOs (dental health maintenance organizations) or PPOs. DHMOs and Dental Point of Service (DPPO) plans require you to choose a primary care dentist from their network.