health and if you have coverage, you’re more likely
to visit your dentist. Those visits can help prevent
and monitor dental health issues that could
lead to more serious conditions and require more
expensive treatment, such as cavities, tooth removal,
root canals and even oral cancer.
The good news is that Americans have more choices
for dental coverage than ever. Though many people
with dental benefits get them through their employers,
individual plans are also available through the new
Health Insurance Marketplaces established by the
Affordable Care Act.
It’s important to know all your options when choosing
the right dental plan for you and your family. Use
Do I really need a dental plan?
For some people, buying dental benefits may cost
more than paying a dentist’s office directly. When
considering a plan—especially if it’s not provided through
your employer—ask yourself the following questions
to estimate how much you might spend out-of-pocket:
• What is your plan premium?
• What is your plan’s deductible?
• What is your co-payment?
• What percentage of treatment costs (coinsurance) will I pay?
When you consider the total cost of your dental
treatment, you must remember to include the cost
of the dental plan itself.
Another important factor to consider is what kind
of care you regularly receive from your dentist. Are
your regular checkups enough, or do you routinely
need procedures (like cavity fillings) performed? Talk to
your dentist about your dental history and possible
care needs before making your decision. Because your
health is always changing, revisit these conversations
with your dentist before your policy is renewed each
year, or when it’s time for you to choose your benefits
at work when you’re hired or during open enrollment.
Notice that we have used the term dental benefit plan
and not dental insurance. Insurance plans are designed
to make you whole in the event of a loss. Insurance, by
definition, entails a risk of loss to the insurance company.
Typical dental benefit plans are not designed to
cover all dental procedures, and dental benefits coverage
is not based on what you need or what the dentist
How do dental benefits work?
Dental benefit plans are not designed to cover all dental
procedures. Plans usually cover some, but not all, of your
dental costs and needs. Many plans involve a contract
between your employer and a dental plan, but you
can also purchase individual plans on your own or
through the Health Insurance Marketplaces.
Your dentist’s main goal is to help you maintain good
dental health, but not every procedure your dentist
recommends will be covered. To avoid surprises on
your bill, it is important to understand what and how
much your plan will pay
What does my dental plan cover?
Even for covered services, most plans share the costs
of treatment with you. If you have benefits through work,
the amount is determined by how much your employer
pays into the plan. If you have an individual plan,
the terms will be spelled out in a contract.
Although you may be tempted to make dental care
decisions based on what your plan will pay, the least
expensive option is not always the healthiest option.
Before committing to a plan, make sure you understand
how you and your plan share costs. This is done in several ways:
A deductible is typically applied to all services and
must be paid by you before your plan coverage starts to
pay. Most plans don’t require a deductible for preventive
and diagnostic services.
In most cases, you will be expected to pay a percentage
of the dentist’s
charges or allowed benefit amount. This is called
coinsurance. For example, your plan may pay 80%
and you pay the remaining 20% owed to your dentist.
This is the maximum dollar amount a plan will pay
during the course of the plan year. You pay anything
over that dollar amount. For example, if your annual
maximum is $1,500 and your dental expenses top
$3,500, you are responsible for that additional
$2,000. If the annual maximum of your plan is too
low to meet your specific needs, you may want to ask
the plan how you can get a higher annual maximum.
Also, if your plan covers braces, there is usually
a separate lifetime maximum limit.
Your dental plan may not cover conditions you had
before enrolling even through treatment may still
be necessary. You would be responsible for paying
these costs. For example, benefits may not be paid
for replacing a tooth that was missing before the
effective date of coverage.
Fixed Dollar Amount (Capitation) Programs
In these programs, you pay a fixed dollar amount for
each dental visit or specific treatment. The rest of
the treatment cost is covered by the program.
Types of dental plans: Which one is right for you?
PPO and DHMO: alphabet soup or dental plan? Sorting
through different dental plans can sometimes feel
overwhelming. Get a breakdown of your options, and
find out which one is best for you.
Preferred Provider Organization (PPO)
A PPO is a dental plan that uses a network of dentists
who have agreed to provide dental services for set
fees. The number of dental services covered depends
on the plan. If you have a PPO plan and see a dentist
out of the network, you will most likely have
more out of pocket expenses.
Dental Health Maintenance Organization (DHMO)
A DHMO is like an HMO. Network dentists are paid a set
fee every month to provide covered dental services to
you whether you see the dentist or not. Typically,
some of the covered services have no cost to you,
or you may have to make an out of pocket payment for
Discount or Referral Dental Plans
Discount and referral plans are technically not
benefit plans. The company selling the plan contracts
with a group of dentists. These groups of dentists agree
to discount their dental fees. Discounts are usually
applied to all services including cosmetic. These plans
do not pay for any services received, instead, you
pay the full cost of treatment at the reduced rate
determined by the plan.
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