Dental insurance, like health insurance, pays a portion of the costs associated with dental care. Also like health insurance, dental insurance can be a confusing maze of options.
Most if not all individual plans pay very little, have low annual caps, and have very long waiting periods before most procedures are covered at all. Generally speaking, we do not recommend our patient purchase individual dental insurance plans. We have found they usually come out ahead financially by simply putting what their premium would have been into a savings account and “self insuring” their dental care.
Here is what you need to know to make an informed decision concerning your dental insurance.
Types of Dental Insurance
Dental insurance is offered in three different forms, with a fourth non-insurance option also available. Which type to choose depends on your individual situation.
- Dental HMO: If you choose a dental HMO (health maintenance organization), your insurance will pay only for those dentists who are part of the network. Out of network dental care may (or may not) be covered in an emergency, but all of your regular care must be provided within the network.
This is often the least expensive alternative, and can be a great choice if you have a dentist that you like and trust who happens to be part of the network. However, if your preferred dentist is out of network, or if you travel frequently, you will probably find that a dental HMO is too restrictive. Due to their restrictions and low reimbursement rates we are not members of any HMO plans.
- Dental PPO: A dental PPO (preferred provider organization) is something like a less-restrictive HMO. You can visit whatever dentist you choose, whether or not that dentist is part of your network. However, you will pay less when using an in-network dentist.
This is a moderately-priced option that fits the way many people use dentists. You can select someone in-network for your regular dental care, but have the freedom to see someone else when traveling, or for services that your regular dentist does not provide. We are members of several PPO organizations.
- Dental Indemnity: Dental indemnity is the most expensive option, but can be an excellent choice for those who travel frequently or whose preferred dentist is not part of a network. With this type of plan, you are free to see any dentist you like, provided that the dentist is willing to accept the insurance. Most dental indemnity plans cover services only in the United States, although some will cover border towns in Mexico and Canada as well.
- Dental Discount Plan: Although it is not actual insurance, a dental discount plan can save you some money at the dentist’s office. You must choose a dentist who accepts the plan, but you will receive all of your dental care at negotiated discount rates. Dental discount plans cost only a few dollars per month, and can be combined with insurance coverage, making them a great option for those whose preferred dentist accepts their plan.
Types of Services
Dental insurance divides covered services into three categories: preventive, basic, and major. There is a heavy emphasis on preventive care, which tends to be covered at a much higher percentage than basic or major services. In addition, many dental insurance companies have loyalty incentives, in which each category of services is covered at a higher percentage after the first year.
Preventive care includes such services as cleanings, exams, and X-rays. The goal is to prevent dental issues before they begin. Preventive care is normally covered right away, at 80 to 100 percent of the total cost, and is almost always covered at 100 percent by the second year.
Basic care includes fillings, root canals, and other services to save a tooth. Basic care may be covered right away, or there may be a 6 to 12 month waiting period. Basic care is typically covered at 80 percent, depending on the insurer and how long you have been insured.
Major care includes crowns, bridges, dentures, and other major restorations. A few insurers cover it right away, at around 25 percent, but a waiting period of 12 to 18 months is far more common. Major care is generally covered at 50 percent after the first year.
Exclusions and Limitations
Certain services, such as orthodontics and dental implants, are handled differently by different dental insurance companies. Some consider these to be major services and cover them accordingly. Some do not cover them at all. Some cover them only for minors. Some categorize them separately, with separate annual and lifetime maximums. If you suspect that you or a family member will need these services, be sure to read the fine print before signing up.
As a general rule, dental insurance is governed by annual maximums, often in the range of $1000 to $1500 per year. Any dental work over that cost is at your own expense. A few companies will cover as much as $3500 per year in exchange for a higher monthly premium, so if you need extensive dental work, choose a company with a higher cap.
All dental insurance companies, except discount plans, have annual and lifetime limits on specific services. For example, you might be eligible for two cleanings per year and one set of dentures every 10 years. Read your policy carefully for details.
Direct Pay vs. Reimbursement
Some dentists, particularly those participating in an HMO or PPO, charge you only your expected portion of costs and bill the rest to your insurance company. Others will file the insurance paperwork, but expect you to pay out of pocket for the entire bill and then wait for reimbursement from your insurer. Neither is “correct,” but this could be a factor in choosing both a plan and a dentist. At our office we handle all your insurance billing and typically ask for your portion of the payment at the time of service.
At Family Dental Care of Bellevue, we are committed to providing quality dental care to our patients and their families. We are proud to have been voted one of the best dental offices in Washington State. If you are ready to take the first steps toward improving your dental health, we invite you to call 425-643-5778 today to make an appointment for your initial consultation.