What is Dental Insurance

Dental Insurance.  What is it and how does it work?

The title on the page seems like a simple question, doesn’t it?  Dental insurance is insurance.  You go to the dentist, they bill the insurance, the insurance pays for the appointment.  Simple, right?

Maybe not.  What if your dentist is not in-network?  What if your insurance has limitations on how often you can get your teeth cleaned and your appointment is one day shy of exactly 6 months?  What if the new plan you just bought doesn’t pay for fillings until you’ve had it for 6 months?

It can truly be more helpful to think of Dental Insurance not as insurance, but as a gift card that has a set dollar amount and limits on how those dollars can be spent.  The purpose of this article is to try to explain the different kinds of Dental Insurance and Dental Discount Plans that are out there, and hopefully provide you, our patient, with a better understanding of what to expect from your insurance coverage.

I must give you a warning.  There IS NO SET WAY THAT INSURANCE COMPANIES COVER TREATMENT.  Every insurance plan has its own rules.  I am setting forth the most common situations I’ve experienced, but I am always surprised at new limitations I find in insurance policies. 

Terminology:

  • Fee Schedule:  list of costs of all services provided in dentistry.
  • Network:  A company that contracts with dentists to accept a specific fee schedule.  A network may be specific to a single insurance company (such as the CIGNA network) or may encompass multiple insurance companies (such as Connection Dental).   
  • Subscriber:  The person who is attached to the dental insurance.  Either the purchaser of the policy, or the employee of the company that purchased the policy.
  • Annual Maximum: the amount of money the insurance will pay out yearly, it can range from $250 to $2500 or more.  Typically, it’s $1000-$2000.
  • Deductible:  The amount the patient must pay before the insurance starts paying.  This is usually applied annually, and usually only applies to treatment (fillings, crowns) and not preventative services (cleanings, exams).  The cost can range from $25-$100, or more if it’s attached to medical insurance (more on this later).
  • Frequency:  How often insurance will pay for certain procedures.  Common frequencies are once every 6 months for cleanings, or 2 times in a calendar year for cleanings (this is two different frequencies and need to be paid attention to), every 5 to 10 years for crowns, every 2 years for Periodontal treatment.
  • Limitation:  Things the insurance company or network will not pay for.  This can involve specific treatment (night guards), frequency of treatment, waiting periods…. anything they can think of that will reduce what they pay out.

Types of Dental Insurance:

Fee for Service or Indemnity:  Dental insurance that does not have a network.  They will pay based on the insurance fee schedule, which usually (but not always) is within the fee schedule of most offices.  The patient is responsible for any difference. 
What this means to you: You can go anywhere.  The insurance usually will pay the dental office directly, but not always, they may require you to pay up front, and then will reimburse you.

PPO:  Preferred Provider Organization:  Dental plans that have an agreement with individual dental offices where the office has agreed to accept the insurance company fee schedule, and not charge the patient the difference between that and the dental office fee schedule.  Most PPO plans WILL PAY if you go out of network, but they may not pay as high of a percentage of treatment, or they may pay based on the insurance fee schedule, leaving the difference up to the patient to pay.  
What this means to you:  you will save money by seeing a provider in-network.

EPO:  Exclusive Provider Organization.  This is a preferred provider program but will ONLY pay if the dental is in-network. 
What this means to you:  you must go in-network, or the insurance won’t pay for your treatment.

DHMO: Dental Health Maintenance Organization:  Dental plans that will only pay one provider that the patient is assigned to for services.  Instead of the office being paid for services provided, it’s paid a set amount monthly for every patient assigned to the office, regardless of if that patient was seen in the office. 
What this means to you:  You have the least amount of control over your care with this type of insurance.  The offices that accept this tend to limit how much treatment is done per patient, and the insurance will only cover the least costly treatment (for example, a partial instead of a bridge).

Privately Purchase Insurance:  This is insurance that is purchased on the market, not provided by an employer.  It can be Fee for Service, PPO, EPO, or DHMO.  This insurance usually has waiting periods attached, such as only paying for cleanings and exams for the first 6 months, then adding fillings at that point, then adding everything else after 12 months.  They may also pay for everything immediately, but at a greatly reduced rate, which will increase the longer you have the plan.  Finally, there are policies that don’t pay as a percentage of billed services, but a strict dollar amount, which is usually very low. 
What this means to you:  It is important that you understand exactly what the policy is, what it pays for and when, BEFORE you purchase it.

Dual Insurance: When a patient has dental insurance through 2 or more sources, such as a husband and wife who both receive insurance through their employers and are also covered on the spouses’ policy. 
What this means to you:  This can mean that the patient pays very little, if anything, out of pocket for most services.  However, there can also be limitations where the secondary policy does not pay.  It’s important to know exactly how each policy is written.

Supplemental Insurance:  A policy that pays a set dollar amount for whatever treatment is done.  It may include all treatment, or limited treatment.  AFLAC is an example of this.  Supplemental insurance is NOT considered dental insurance, although it may pay out for dental procedures. 
What this means to you:  This type of insurance pays out regardless of any other policy.  If you also have a regular dental policy, it can mean that more is paid for the service than the service costs (the extra money belongs to you).  It is not considered dual insurance.

Pediatric Medical Insurance Rider:  This is insurance for children age 18 and younger that is part of a medical insurance plan.  There is a huge range of how they will pay for services, they may require the medical deductible to be met before any services are paid, and they may only pay if the dentist is in-network.  They also do not have an annual maximum, and most will cover 100% after a certain threshold has been met. 
What this means to you:  Always go in-network and try to get a full understanding of what the insurance will cover.

Medicare Advantage Plans:  Some Medicare supplemental plans offer very limited dental insurance.  In some cases, it’s included, in others it’s offered at an additional cost.  These are usually PPO plans. 
What this means to you:  These plans have a wide range of what they pay for, make sure you understand what they cover and if your dentist is in-network.

Commercial Discount Dental Plan:  These are NOT insurance plans.  These are Insurance networks that are selling their network fee schedule to you.  There is usually a nominal yearly fee.  They do not pay anything towards your treatment.  You must go to a dentist that is in-network with the plan. 
What this means to you:  This gives you access to the same discount fee schedule that an office has agreed to accept for patients who have insurance coverage, so you can save 10-40% depending on the plan.

In-Office Membership Plans:  These are plans that individual dental offices set up to allow patients without insurance to pay a lower amount for their services.  We offer a Dental Plan at Today’s Dentistry, there is a yearly fee per person, but that fee provides cleaning and exams, and all other treatment receives a 20% discount.   
What this means to you:  This type of plan allows patients to access similar fees as insurance companies, and all money spent goes towards services.

The last thing I’d like to leave you with is the Dental Office role in dental insurance.  While a dental office may have a contract with an individual insurance company (PPO or DHMO plans), that contract only covers the fee schedule the dentist can charge the patient.  In other words, our agreement with an insurance company allows the company to pay us at their fee schedule.  Any other agreement is with your employer, or directly with you if it is a self-purchased plan.  We have no control over the things they pay for or the limitations they set.  We do the best we can to get all the information to quote you correctly; but we can be surprised.  I would encourage anyone with insurance to understand their plan, to help us help you to get the most out of your coverage.

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