• Real Dental Insurance Facts
  

• Real Dental Insurance Plans
  Consolidated Plans (Health and Dental)
  Dental Insurance Plan Models (Managed Care, Fee-for-Service)
  
  
• Individual Coverage
  
  
• Spousal Coverage
  
  
• Prior Authorization Requirements
  
  
• Questions to Ask Before Choosing a Plan
  
  
• Real Dental Insurance Important Points

Real Dental Insurance Facts

According to the American Dental Association, more than half of the population in the United States is not covered by real dental insurance. For those who do have dental coverage, most often it is through an employer.

Real dental insurance is designed to pay costs associated with dental care. It helps to pay a portion of the bills from dentists, hospitals, and other providers of dental services. As such, dental insurance provides for affordable family dental care. It protects you from any financial burdens caused by unexpected dental expenses.

Real dental insurance involves a business arrangement made between an insurance company and an employer. Most plans are designed to pay a portion of dental costs. However, some real dental insurance plans may exclude or discourage certain treatments, such as dental sealants, which can prevent tooth decay and save money in the long run. Carefully read the dental insurance plan and understand its limitations. If a plan does not cover a procedure that is recommended by your dentist, this does not mean that the treatment proposed isn't appropriate or needed.

Real dental insurance can be somewhat of a complicated process. In order to obtain dental insurance, a patient usually goes through a lengthy paper work process, a review of pre-existing conditions, and a waiting period. When a procedure is performed, a claim is filed to the insurance provider, and payment is sent to either the dentist or the patient. It is not uncommon for the patient to pay a deductible in addition to monthly dental insurance premiums. Finally, since all insurance companies are structured differently, policies, fees and claims process procedures will often vary.

Some employers may offer more than one real dental insurance plan to their employees. In fact, the right to choose between two plans could be the law in your state. To understand and make decisions about your dental benefits, it is important to remember that plans are often very different. To make the best decision for affordable family dental care, it is important to understand exactly how the different kinds of dental insurance plans work and how they calculate their cost savings.

Real Dental Insurance Plans Consolidated Plans and Dental Insurance Plan Models)

Consolidated Plans (Health and Dental)

Health and dental insurance plans can be consolidate, in order to provide an effective, comprehensive method of affordable family dental care protection. This is especially true if the plans compliment each other.

In some cases, it is possible to purchase a dental insurance plan that is an extension of your medical plan. While medical insurance is designed to cover the costs of diagnosing, treating and curing serious illnesses, dental insurance coverage involves routine preventive dental care. Consolidation strengthens both forms of insurance because the administrative portion can either be consolidated or related to each portion of the coverage. For instance, in the case of an oral disease such as cancer, while there is no overlap, there is a delineation between which policy covers the examination and which covers the treatment component.

The partnering of health and dental insurance is particularly true in the case of a Health Maintenance Organization (HMO) plan. While an HMO may not be the best option for some people, it is a supplement to their health insurance. An HMO plan offers prepaid service within a network. The advantage to this coverage is that a patient can be seen by a physician or dentist whenever necessary. The disadvantage is that there are many restrictions placed on the patient, including the choice of a health care provider. The patient must use personnel and services within the network and is penalized for going outside the coverage network area.

If possible, you should purchase a real dental insurance plan that is consolidated. Policies can be flexible and you may be able to customize a policy to suit your particular needs. Try to be very specific about what you are looking for in a real dental insurance plan. It is also good to think about affordable family dental care future needs. A few years from now, you and your family may be faced with gum disease, cracked teeth, or orthodontic problems. In choosing real dental insurance, you want to be certain that your family’s current and future needs will be met.

Another reason a consolidated dental plan may be beneficial for some individuals is due to the fact that some symptoms may at first appear to be a dental issue but with further diagnosis, reveal itself to be a medical one. For instance, halitosis (bad breath), is often seen as a dental disease attributed to inadequate teeth cleaning or gum disease. But, halitosis can also be associated with a stomach condition. If halitosis is attributed to a gastrointestinal problem, no amount of oral hygiene can correct it. It would be necessary to treat the condition medically.

While it is common for real dental insurance plans to exclude treatment that is covered under the company's medical plan, some plans go on to exclude or discourage necessary dental treatment. This may include such dental treatments as sealants, pre-existing conditions, adult orthodontics, and specialist referrals. Even when you and your dentist agree on the treatment plan, the contract provision of the real dental insurance plan may only pay a portion, or the least expensive alternative treatment (LEAT) as determined by the insurance company. Some real dental plans may also exclude treatment performed by family members. While patients need to be aware of the exclusions and limitations with real dental insurance plan, they should not let those factors determine treatment decisions.

Dental Insurance Plan Models

In addition to a consolidated insurance plan, there are a number of other real dental insurance plan models. These models have different options for choosing a dentist. Some dental insurance plans limit your choice of dentists, while others allow you the freedom to choose your own dentist. While they may be referred to as open panel (freedom of choice plan), and closed panel dental insurance plans, the most common designs are grouped into two categories: managed care and fee-for-service dental insurance plans.

Managed Care dental insurance plans are cost containment systems that direct the utilization of health care by a) restricting the type, level and frequency of treatment; b) limiting the access to care; and c) controlling the level of reimbursement for services. Examples of managed care plans are Preferred Provider Organization, Dental Health Maintenance Organization and Table or Schedule of Allowance plans.

Preferred Provider Organization (PPO) programs are a type of real dental insurance managed care plan in which patients select a dentist from a network or list of providers. These dental care providers have agreed, by contract, to discount their fees.

PPO’s are usually less expensive than comparable indemnity plans if they are employer sponsored. If the employer is paying the monthly premiums for the dental insurance plan and the dentist used is part of the PPO, this may be an attractive option. However, if you are responsible for payment, it may be more expensive and less flexible than a discounted dental insurance plan.

In addition, there are PPO deductibles to consider and most PPO’s only pay a percentage of the charges, leaving the patient with a co-payment charge. PPO’s may also have an annual maximum limit. With PPO’s that allow patients to receive treatment from a non-participating dentist, the patient is penalized with higher deductibles and co-payments. In PPO’s which do not allow patients to receive treatment from a non-participating provider, the patient will have a complete loss of benefits.




Dental Health Maintenance Organization (DHMO) or capitation plans are real dental insurance plans which pay dentists a fixed amount (usually on a monthly basis) per enrolled family or individual, regardless of whether the patients are seen or not. In return, the dentists agree to provide specific types of treatment to the patient at either no charge or with a co-payment (depending upon the procedure.

In theory, DHMO’s reward dentists who keep patients in good health, thereby keeping dental costs low. DHMO models typically offer the least expensive dental plans, however, dentists may end up having to provide services at 'below cost' rates, and not be able to spend as much time with each person as a PPO could offer. Working in an HMO setting, the dentist has many people to see and is compelled to function in an environment where volume matters. Although a patient will be seen and treated, it is difficult for a relationship with the dentist to develop due to a lack of time. For many people, quality time spent with a dentist is a major factor in their decision to be seen by a dental provider.




Table or Schedule of Allowance is a real dental insurance program that determines the cost of a list of covered services. Most often, it does not represent the dentist's full charge for those services and the patient often has to pay the difference.

Fee-for-Service dental insurance plans are typically freedom-of-choice real dental insurance arrangements under which a dentist is paid for each service rendered according to the fees established by the dentist. A Direct Reimbursement Plan is an example of a Fee-for-Service type plan.

Direct Reimbursement Plan


A Direct Reimbursement dental insurance plan is a self-funded plan that reimburses patients according to dollars spent on dental care, not type of treatment received. It allows the patient complete freedom to choose any dentist and does not exclude coverage based on the type of treatment needed. Instead of paying monthly insurance premiums, employers pay a percentage of actual treatments received. In addition, employers are removed from the potential responsibility of influencing treatment decisions due to plan selection or sponsorship. A Direct Reimbursement plan is the ADA's preferred method of financing dental treatment.

Dental Fee-for-Service insurance plans may use the terms "usual, customary and reasonable" (UCR) to determine the portion of the dental treatment fee they will pay. Plans that describe benefits in terms of percentages, for example, 100% for preventive care or 80% for basic services, etc. usually fall under this type of plan. The administrators of fee for service dental plans set the "customary fee" for each dental procedure. These plans pay a set percentage of the dentist's fee or the plan administrator's "reasonable" or "customary" fee limit—whichever is less. These limits are the result of a contract between the plan purchaser and the third-party payer. While fee-for-service limits are called "customary," they may not accurately reflect the fees that area dentists charge.

The fee that the insurance company determines to be "customary" may be very low, compared to the area's average fee for the same services. If your dentist's fee exceeds the customary fee as set by the plan administrator, your benefit will be based on a percentage of the customary fee instead of your dentist's fee. In other words, the plan pays a percentage of the UCR level and the patient is required to pay a greater percentage of the treatment costs. Exceeding the plan's customary fee does not mean your dentist has overcharged for the procedure. There is simply wide fluctuation and lack of government regulation on how a insurance plan determines the "customary" fee level.

Individual Coverage

Individual health dental plan coverage for individuals is not commonly offered because dental needs are highly predictable. For example, an individual would not pay premiums for dental coverage if the premiums were more expensive than the cost of the treatment needed. Since this is often the case, insurance companies would lose money on every individual dental plan they wrote.

There are, however, a few companies that offer a form of individual health dental plan coverage. Most of these plans are called "referral plans" or "buyers' clubs." In these types of plans, an individual pays a monthly fee to a third party for access to a list of dentists who have agreed to a reduced dental fee schedule. Payment for treatment is made directly from the patient to the dentist. The third party is only involved with matching the individual to the dentist, behaving only as a referral source.

Spousal Coverage

If both you and your spouse each have a real dental insurance plan, you may have additional coverage from each other's programs if they cover spouses and dependents. The primary plan for covering your children depends on the regulations in your state. Most plans use the "birthday rule" whereby the spouse whose birthday occurs earlier in the calendar year is the primary insurance provider. Others consider the father's plan as the primary dental insurance. The American Dental Association has recognized the "birthday rule" as the preferred method for coordinating benefits, but which rule applies to your family depends on the language of your dental plan.

If you have two or more potential sources of real dental insurance coverage, check the coordination of benefits language for each plan to determine the benefits available. In no case should the benefit derived from the two coordinated programs exceed 100% of the dentist's charges for treatment.

Prior Authorization Requirements

Real dental insurance plans often contain provisions that will deny dental benefits, or reduce the level of coverage if a treatment plan is not submitted for prior authorization. Third-party payers often request a "predetermination of benefits" on certain treatment plans. Usually this means a dental consultant will review your dentist's treatment plan and determine what benefits your plan will provide. But predetermination is not a guarantee of payment. This is a contractual matter between the plan purchaser (often your employer) and the plan administrator and is contrary to the policy of the American Dental Association.

The American Dental Association is opposed to any dental clause that would deny or reduce payment to the beneficiary, to which he/she is normally entitled, solely on the basis or lack of preauthorization. Nevertheless, you should know how your plan is designed, since this can affect significantly the plan's coverage and your out-of-pocket expense. While it is a good idea to review your benefit prior to receiving treatment, the final treatment decision should be a matter between you and your dentist, regardless of the benefit.

Questions to Ask Before Choosing a Plan

When selecting an real dental insurance plan, keep the following questions in mind:

• Will you retain the freedom to choose your own dentist?
  

• Is the type of treatment determined by you and your dental provider?
  

• Does the plan cover diagnostic, preventive and emergency services?
  

• What type of routine dental care is covered? Does the plan cover preventive services such as sealants and fluoride treatments?

• Does the plan provide for full-mouth x-rays?
  

• What major dental care is covered? Does the plan cover such major work as dental crowns, dental bridge work, dentures, braces, root canals, implants, oral surgery and treatment of periodontal diseases or temporomandibular (TMJ) disorders?

• Does the plan allow for referrals to specialists? If so, will the dentist be limited to a list of specialists from which to choose?

• How does the plan provide for emergency treatment? What provisions are made for emergency care when you are away from home?

• If the plan requires monthly premiums, what percentage of that money goes to actual care and not to overhead or administration?

Real Dental Insurance Important Points

While there may be some advantages to real dental insurance plans, there are also some disadvantages. Annual spending limits, exclusion, limitations, deductibles and waiting periods for certain dental procedures just to name a few. In addition, claim form submissions are often required for reimbursement. Annual deductibles can range from $25 to $50 per covered individual, while premiums can range from $30 to over $100 per month, depending on the dental insurance policy.

With a real dental insurance plan, while you may always go to the dentist of your choice, you lose benefit coverage for the treatment if it is provided by a non participating dentist. With a PPO plan, patients are given a financial incentive to go to certain dentists and receive some level of dental benefit, regardless of the treating dentist. Other plans, such as capitation programs, do not provide any benefit coverage for treatment given by "non-participating" dentists.

Whether an affordable dental plan provides the coverage your family will need should be the primary consideration when deciding upon a plan. If your employer offers more than one plan, review the exclusions and limitations of the coverage, as well as the general categories of benefits for each plan. Discussing your family's current and future dental needs with your dentist, before deciding on a plan, is also a good idea. While dental benefit coverage should be taken into consideration, you and your dentist make the decision about your treatment plan. Dental insurance coverage should not be the deciding factor in determining the choice of treatment.

Some dental insurance plans may only provide the level of benefit allowed for the least expensive way to treat a dental need, regardless of the decision made by you and your dentist. Sometimes, an appeal to the third-party payer, requesting an increase in the benefit allowance will work, but there are no guarantees that the plan administrator or insurance company will approve the request. It's also important to have adequate coverage for your situation, so you can access the features you need and aren't paying for something you won't use.

Many dental insurance plans have restrictions, such as pre-existing conditions and annual maximum payments, and therefore, may not necessarily be the most cost effective type of coverage. If you are covered through your employers dental plan and are looking to supplement your plan, a good option may be a discounted dental plans.

Discounted dental plans have become quite popular, and there are plenty of companies competing for your business. Learn more about this fast growing dental option. Then compare features of both conventional insurance plans and discounted dental plans, then decide which is the best choice of dental insurance plan for your situation. Enter Here to learn more.

Wishing you well with your dental needs,
The Dental Clinic Manager

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