Selecting a Dental Insurance Plan

Herrick Dental | 04/29/13

There are a multitude of factors to consider when selecting a dental plan. How can you be sure to choose the plan that is right for you?

Generally, you want to select a plan that will meet your current oral health needs and offer coverage for potential issues or emergencies in the future. You also want to balance value, access to quality care (i.e., dentists who meet your care needs, accept your plan, and are located within a reasonable driving distance), and service (does the insurer offer telephone support, online tools, dental health resources, efficient payment, etc.?).

To further help with your decision, we also suggest that you become familiar with the following coverage details before selecting a dental plan.

Covered Services

Nearly all dental plans provide coverage for preventive and diagnostic care, such as exams, cleanings, x-rays, and fluoride applications. Most plans also cover basic restorative procedures, which can include fillings, sealants, simple extractions, space maintainers, oral surgery, biopsies and non-surgical periodontics. Some plans cover major restorative services, such as crowns, bridges and dentures. Generally, insurers provide 100% reimbursement for preventive services, 80% reimbursement for minor restorative procedures, and 50 to 60% reimbursement for major restorative services. Take note that Dental Health Maintenance Organization (HMO) and discount plans are structured differently than traditional Fee-for-Service plans. Be sure to learn the plan type and reimbursement structure before
selecting coverage.

Participating Dentists

Dentists who contract with the insurance company are known as participating dentists. These dentists usually agree to accept the insurer’s reimbursement allowance for covered services as payment in full (excluding any applicable coinsurance, copayment or deductible) and agree to file claims and other paperwork on your behalf. When choosing a dental office, be aware that there is a difference between a participating dentist and an accepting dentist, who generally agrees to file claims and accept payment from an insurer, but may bill you for the difference between their charge and the insurance company’s reimbursement.

Out-of-Pocket Costs

These expenses (most commonly deductibles, coinsurance and copayments) are the patient’s responsibility. A deductible is the amount the patient must pay for some covered services before the plan begins reimbursement (preventive services are generally excluded from deductible requirements). Coinsurance is the patient’s share of the plan’s allowance. For example, a covered service that is paid at 60% by the plan results in a 40% responsibility for the patient. Under certain dental plans (such as a DHMO), a copayment is the amount that the patient is required to pay when the service is provided.

Waiting Periods

These are set time periods during which a patient must be enrolled in a plan before being eligible for covered services or a specific category of covered services. For example, a patient may be immediately eligible for reimbursement of diagnostic and preventive services, but may have a waiting period of 12 months for major restorative services.

Exclusions and Limitations

Generally, not all dental services are covered by a dental plan. The plan may have specific conditions or circumstances that exclude or limit reimbursement. Limitations are related to time or frequency. For example, a patient may only be eligible for two cleanings in a 12 month period. Exclusions are services that are not reimbursed by the plan. For example, cosmetic procedures (such as tooth whitening) are usually not covered.

Annual and Lifetime Maximums

An annual maximum is the total amount an insurer will pay for dental services provided to a patient in a specific period, typically a calendar year. A lifetime maximum is the total amount an insurer will pay for the life of the patient or plan. Lifetime maximums generally apply to specific services, such as dentures or orthodontia.

Should you have questions regarding your dental insurance options, talk with us or human resources representative.

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