What is the difference between dental insurance and dental discount plans?


Q. What is the difference between dental insurance and dental discount plans?

A. They can both be helpful in lowering your overall dental costs, but they vary widely in terms of the benefits you get and how much you pay for the coverage.

Dental insurance

Dental insurance plans work like Medicare. You or your employer pay a monthly premium. Once the deductible is reached (assuming there is a deductible; dental HMOs often do not have a deductible), the insurance pays all or part of your eligible dental expenses, up to a stated maximum. The insurance company usually pays the dentist directly for their share of your dental costs, although dental insurance plans may require you to pay the bill up front and then seek reimbursement from the insurance plan.

Dental insurance plans generally have deductibles, copayments, waiting periods and / or policy limits. A typical deductible could be $ 25 to $ 100 per person per year. Thereafter, the plan will offer benefits that vary according to the type of care received. Preventive care is often fully or almost fully covered. But the patient will usually have to pay part of the cost for more extensive care. On some plans, the patient pays a percentage of the total cost, while other plans have a schedule of benefits with fixed amounts that the patient will pay for various procedures. On most dental plans, the maximum annual benefit typically ranges from $ 1,000 to $ 2,000, although there are outliers on both ends.

Dental HMOs require the insured to select a primary care dentist from the plan’s provider network, and all care must be coordinated by that dentist; off-grid dental care would generally not be covered by an HMO. Dental HMOs generally do not have maximum benefits; instead, they will have a fixed co-payment amount that the insured pays for each procedure. (Here is an example of the benefit schedule of an HMO dental plan.) Dental HMOs are more common for employer sponsored dental plans than in the individual market. If you purchase your own dental plan, most of the options available will have a maximum annual benefit.

Dental OPP allow policyholders to choose from any dentist in the network of providers, and most will also offer partial benefits if the policyholder requests treatment from a dentist who is not part of the network. Dental PPO plans generally have a deductible and maximum annual benefit, and cover a percentage of each dental procedure according to whether it is classified as preventive (eg, x-rays, cleanings), basic (eg, fillings, root canals, extractions) or major. (eg crowns, implants, dentures, oral surgery). It is also common for plans to include waiting periods for basic and major services; common waiting periods are six months and 12 months, respectively, although they vary from plan to plan.

Dental compensation plans allow policyholders to see any provider, without network restrictions. Dental benefit plans will pay a predetermined percentage of the “usual and customary” fees for a given procedure, which means you will pay more if you visit a dentist who charges more than the “usual and customary” amount. Since there is no network for a compensation plan, dentists are not required to limit their fees based on a network contract. Compensation plans typically have a deductible, maximum annual benefit, and waiting periods for non-preventive care, just like PPO plans.

Typical dental insurance premiums are $ 20 to $ 50 per month for an individual and $ 50 to $ 150 for a family, but they vary widely depending on the type and extent of coverage. If your employer offers the plan, they may pay part of the premium for you. If you buy the plan yourself, you will pay the full cost yourself. The ACA premium subsidies do not apply to stand-alone adult dental plans, even if they are purchased through your state’s health insurance exchange.

For children, pediatric dental coverage is one of the ACA’s ten essential health benefits, and premium subsidies sometimes offset part of the cost of a stand-alone pediatric dental plan. But even with ACA regulations, dental coverage, price, and plan availability vary widely from region to region.

Dental discount plans

Dental discount plans differ from dental insurance primarily because they do NOT pay dental fees for you. Instead of, they offer reduced prices participating dentists.

There is generally no deductible, no waiting period and no annual maximum. Typical discounts range from 10 to 60 percent for normal dental care. The plans cost as little as $ 100 per year for individuals and $ 150 for families.

If you know you will need significant dental care, a dental insurance plan with benefit limits and waiting periods might not help much. But a dental discount plan could save you a lot more than the cost of its membership fees, especially if you need multiple dental procedures over the course of the year. Since the benefits of membership for an individual are typically less than $ 150 per year, a member would even get small discounts on a few important dental procedures. But it’s important to keep in mind that even with a dental discount plan, you’ll still be paying a significant portion of the cost of dental care, especially if you need major work.

If you are considering a discounted dental plan, contact some of the dentists in the network and discuss the actual costs with them to determine how much you will save using the plan. (Note that dental rebate plans are not the same as medical rebate plans; the latter should generally be avoided, as reimbursable medical expenses can climb without health insurance).

Other discount options

It is also helpful to know that some dental discounts can be obtained just by requesting them. A dentist may be willing to offer you a business discount for accepting permanent semi-annual appointments, paying in cash at the time you receive services, or referring other patients. For those who do not yet have a dentist, free examinations and x-rays are frequently offered to new patients.

Low-cost dental care is also available at dental schools, and many communities have charitable dental programs available for low-income patients. Shop around for discounts before getting dental treatment, even if you don’t have any kind of dental coverage.

Louise Norris is an individual health insurance broker who has written on Medicare and health reform since 2006. She has written dozens of opinion pieces and educational articles on the Affordable Care Act for healthinsurance .org. His updates on the state health exchange are regularly cited by media outlets covering health reform and other health insurance experts.


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