What you need to know when choosing dental insurance


While the thought of sitting in a dentist’s chair makes some people anxious, the potential cost keeps a lot of it as well. If you’ve purchased dental insurance from your employer or can afford to buy it yourself, you’ll want to choose a plan that covers the dental care you and your family will need now and in the future.


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According to the American Dental Association, the cost of dental care is a barrier to care for many consumers, more so than for medical care, prescriptions, mental health care, or vision care.

But on the bright side, dental costs tend to be easier to anticipate (and smaller) than the wide array of medical bills any of us could incur at any given time. Some dental treatments will remain an unexpected emergency, such as breaking a tooth. But less obvious dental needs can often be predicted (or avoided!)

Other needs to consider are whether you or a member of your family might need more extensive dental care, such as braces or other orthodontic appliances, dentures, dental implants, crowns or braces. bridges. While most dental insurance plans will cover at least part of the cost of these more expensive treatments, the patient will also tend to pay a significant amount. On the flip side, many dental plans cover the lion’s share of the cost of more common care, such as exams, cleanings, and fillings.

What is included in a dental plan?

Several types of services are included (to varying degrees) in typical dental plans:

  • Routine and preventive care: These include periodic examinations, cleanings, x-rays and fillings; fluoride and sealant applications to prevent cavities; and certain types of oral surgery, gum care (also called periodontology), and root canal treatment.
  • Emergency care: This includes repairing or removing a cracked or broken tooth and treating it after an accident involving the mouth and teeth.
  • Complex care: This includes orthodontics, dentures or bridges. Many dental plans cover about half the cost of these types of procedures.

Types of dental plans: indemnity, managed care and discounts

Dental free choice plans, also known as dental compensation plans, offer the highest level of flexibility because they do not have provider networks. The member is free to use any dentist, and the plan will reimburse according to their fee schedule. But that doesn’t mean the plan will cover the full cost; the member is responsible for paying the difference between what the dentist bills and what the plan pays, and some dental insurance plans have very low coverage limits.

Since there is no supplier network contract with a compensation plan, dentists are not required to write off part of their bill – they can collect the full amount, including billing the consumer for the total cost remaining after the insurance plan has paid the amount it is willing to pay for that particular service. [This is in contrast with what most Americans are used to in terms of their health insurance: Since most health insurance plans are managed care plans with contracted in-network providers, most of us are accustomed to an EOB for medical care that shows the amount the provider billed, the amount that’s written off under the terms of the insurer’s network agreement, and then how the patient and/or the insurance company cover the portion that’s left.]

But many dental plans are managed care plans that require patients to choose from a pre-approved list of dentists from a network of providers who have agreed to cut their fees. These plans can be dental PPOs or dental HMOs, and the rules are quite similar to medical PPOs and HMOs, the latter generally offering no coverage if the member is receiving care from a dentist who is not a member of the dental office. network of plan providers.

Since dental HMOs tend to be more restrictive and do not cover out-of-network care, their premiums also tend to be lower than dental PPOs premiums, if the coverage amounts are similar. But you can get a dental HMO more expensive than a dental OPP, if the HMO offers higher coverage amounts and has a higher benefit limit. Dental benefit plans tend to offer the highest premiums for comparable amounts of coverage because they give the member the most flexibility in which dentists they can use. But you will often find that the dental compensation plans available have lower coverage amounts, which compensates for the flexibility that the plan gives you in terms of choosing a dentist.

There are also dental discount plans, which are not actually insurance. These plans offer a discount when you see dentists who have agreed to be part of the discount plan network, but the plan itself pays nothing for the cost of your care – you pay for your own treatment, albeit at reduced price.Dental discount plans tend to be less expensive than dental insurance, and they generally do not have waiting periods before you can start receiving discounts (dental insurance plans often have long periods of time). (waiting for benefits to take effect, especially for expensive dental treatment).

The Affordable Care and Dental Insurance Act

Beginning in 2014, the Affordable Care Act began requiring all new individual and small group health plans to cover ten essential health benefits. One of these benefits is pediatric dental care.But the rules for pediatric dental coverage are not the same as the rules for other essential health benefits. If you purchase health insurance in exchange for your state, it may or may not include pediatric dental coverage. As long as there is at least one stand-alone pediatric dental plan available for purchase, insurers are not required to incorporate pediatric dental coverage into the medical plans they sell, unless a state requires it. , and some do.

If you purchase a stand-alone pediatric dental plan, it will cap the total reimbursable expense for pediatric dental care.For 2021, as was the case in 2020, disbursements under a stand-alone pediatric dental plan cannot exceed $ 350 for a child, or $ 700 for a family plan that covers more than one child.

This limit on reimbursable expenses for stand-alone pediatric dental plans contrasts with most adult dental plans, which cap the total. advantages instead of. In other words, most adult dental plans limit the amount the plan will pay for your care (typically in the range of $ 1,000 to $ 2,000 per year), while the ACA requires that pediatric dental plans limit the amount of member must pay out of pocket expenses and there is no limit to the amount the insurance plan may have to pay.

If you are purchasing a medical plan that includes built-in pediatric dental coverage, the plan can be designed so that pediatric dental expenses are factored into the plan’s overall deductible and disbursement limit (which cannot exceed 8 $ 550 for a single person in 2021).The total amount of spending is always capped, but if a child needs alone For dental care during the year, the family’s personal expenses may be higher than they would have been with a stand-alone dental plan, since the overall health plan deductible will tend to be higher.

Dental coverage for adults was not addressed in the Affordable Care Act. There are a variety of adult dental plans available for sale, but they are not regulated by the ACA.

Dental plans and costs

If you get your dental insurance through your employer, you may only have one plan option available. But a larger employer may offer you a choice of plans, and if you purchase your own dental insurance, you can choose from any plan available in your area.

So how do you choose? The top three factors are probably which dentists you can see, how much you will need to pay in monthly premiums, and how much out-of-pocket expenses you think you can comfortably manage.

As described above, some plans will allow you to see any dentist, while others will limit you to dentists in a particular network. But while a plan that lets you see any dentist looks good at first, it might not be the best choice if it has lower reimbursement rates or a smaller benefit limit.

The affordability of a plan is based on its premium payments (often deducted directly from your paycheck, if your employer offers insurance) and how much of the dental cost you have to pay yourself, or because the plan does not cover them or only covers part of the cost.

For example, a low premium dental plan may cost you less in terms of how much you pay to purchase the coverage, but you may find that you end up paying a significant portion of the cost of complex dental treatments like bridges, bridges, implants or orthodontic appliances. – maybe not the deal you hoped for. Conversely, it can be overkill to pay high premiums for a premium dental plan when your dental history isn’t complicated and you only need the dentist to clean your pearly whites twice a year.

Before choosing a dental plan, visit your dentist and have an exam that includes a series of diagnostic x-rays. Have your dentist assess your overall dental health and determine any complex procedures, if any, that you may need in the near future. This needs assessment should make it clear to you what level of insurance would best protect you and your wallet. While this won’t make it easier to choose a plan, it will simplify your options and needs in determining the optimal match.

But it’s important to understand that if you purchase your own dental insurance (rather than getting coverage from your employer), you’ll likely have a six-month or one-year waiting period before you have coverage for services. that go beyond basic cleanings, x-rays and fillings. So you won’t be able to buy a dental plan that you buy yourself that will cover the crown you hope to get next month.

If you need dental care and don’t have insurance that will cover it, or if your dental insurance has a benefit limit that is too low to cover the extended procedures you need, there are places you can obtain free or -cost dental services in many communities.


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