A dental health insurance plan is designed to help pay costs associated with dental care. It pays a portion of the bills from dentists, hospitals and other providers of dental care. It should protect you from any financial burdens caused by unexpected dental treatments.
If you are fortunate to have dental health insurance, you probably don't have many concerns about access to care. If a problem arises, treatment can most certainly follow. You basically have peace of mind. People without a dental health insurance plan can't claim the same thing. For some, dental insurance is a luxury only afforded to the wealthy or those with good employee benefits.
Unfortunately, we live in times where dental coverage was not considered as important as health insurance. But, recent studies have proven this not to be the case. In fact, more and more studies are suggesting a link between oral health and our overall health. This has led to a rethinking of the importance of dental care and ways to make it more accessible and affordable to people long left out of the safety net.
According to the ADA, more than half of the US population is not covered by a dental health insurance plan. Job layoffs and skyrocketing unemployment has even effected those, who were previously protected. More and more people are scrambling to find ways to afford necessary dental work.
Many conventional dental health insurance plans differ and can be somewhat complicated. Some people pay high deductibles and premiums, are forced to complete lengthy paperwork, undergo reviews of preexisting conditions and/or waiting periods. Some dental health insurance plans may even exclude or discourage certain dental treatments.
Dental health insurance plans generally fall under three types: Consolidated, Managed Care, and Fee-for-Service. A summary of each is outlined below.
Health and dental insurance plans can be consolidated, in order to provide an effective, comprehensive method of affordable family dental care protection. In some cases, it is possible to purchase dental insurance 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 HMO plans, which offer prepaid service within a network. The advantage of HMOs are that patients can be seen by physicians or dentists when necessary. The disadvantage is the restriction on provider of service. Patient must people and services within the network.
Consolidated dental health plans offer some flexibility for you to customize a plan for your needs. It is also common to find dental carriers excluding treatment that is covered by the medical portion of the plan. But, some plans may try to exclude or discourage necessary dental treatment or pre-existing conditions. And even when you and your dentist agree on a course of treatment, the contract provision of the dental health insurance plan may only pay a portion, or the least expensive alternative treatment (LEAT) as determined by them. Some plans may also exclude treatment performed by family members.
Managed Care dental health 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 (PPO), Dental Health Maintenance Organization (DHMO), and Table or Schedule of Allowance Plans.
Fee-for-Service plans are typically freedom-of-choice dental insurance arrangements. A dentist is paid for service according to his/her established fees. Direct Reimbursement plans fall under this category.
Direct Reimbursement Plans reimburse patients according to the amount of money 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. With this plan, employers are removed from the potential responsibility of influencing treatment decisions.
Dental fee-for-service plans often 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 percentage of the dentist's fee or the plan administrator's "reasonable" or "customary" fee limit - whichever is less.
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 the difference. 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.