Consumer's Guide to Dental Insurance and Benefits
Dental insurance is confusing to many people. Dental insurance can provide welcome assistance in meeting the costs of dental care. But no dental insurance can, or does, entirely cover the costs of meeting all necessary dental care.
This guide provides information (in depth) on the inner working of dental insurance plans as well as how they can affect dental care. Before delving into the details, we recommend reviewing more concise insurance information on the prior page.
Some of the following information has been published by the California Dental Association under the title "What everyone should know about selecting and using dental benefits."
Caveat Emptor (Let the Buyer Beware)
Insurance companies are businesses operating to make a profit. This is their primary motive in writing dental insurance contracts with employers or the pubic directly. They are not interested, first and foremost, in your dental health or your economic well being.
Like any purchase, the consumer is well advised to understand the true nature of dental insurance coverage - particularly if paying for the insurance out of pocket or through a program of employee benefits. Insurance agents selling medical insurance coverage to employers have been known to add a low cost dental plan to sweeten the deal. Employers are also well advised to understand exactly what they are purchasing.
Protect yourself when buying or using dental insurance by getting the facts.
Health Insurance is Commonly Misunderstood
It is quite natural to think about health insurance as a means to cover the costs of treatment for serious medical conditions or accidents. But there's another type of health coverage -- dental insurance. Because dental disease is so common, dental insurance may be helpful for you and your family. Many people misunderstand dental insurance plans and mistakenly think any dental needs they have will be covered by insurance.
There's a World of Difference Between Medical & Dental Disease
Unlike medical disease, which can be both unpredictable and catastrophic, most dental ailments are preventable. Preventive care, including regular checkups and cleanings, is the key to maintaining your oral health.
With regular visits to the dentist, problems can be diagnosed early and treated without extensive testing or elaborate and expensive procedures. That keeps the costs of dental care much lower than those of medical care. In fact, total spending for dental care is decreasing. In 1970, it made up 6.3 percent of total healthcare expenditures. But in 1991, dental care's share of health care spending was only 4.9 percent. This trend continued during the following decade as well.
Medical & Dental Benefits Differ, Too
Medical insurance is immensely profitable because insurance premiums are paid for many years by many people who rarely get a serious illness. The total premiums collected each year always exceed the insurance company payouts for those that do require medical attention. So medical insurance can cover costly illnesses, while the insurance companies make a profit.
But everyone needs periodic dental examinations and preventive care. Most people have untreated dental problems that require care as well. If everyone sought treatment for their dental needs, dental insurance premiums wouldn't come close to meeting the total cost of the care. Insurance companies realize less than half of Americans even have a dentist, and few of those with a dentist seek the care they need.
Since most people covered by dental insurance won't be submitting claims insurance carriers make easy money on their premiums. Dental insurance companies exist to make a profit and they also do this by limiting the conditions and procedures covered for people who do submit claims for care. Claims examiners, who have no professional credentials, routinely deny claims for dental conditions that are complex or costly to treat. As a result, dental insurance operates more like automobile insurance plans, than medical insurance plans.
Different Types of Dental Insurance
There are different types of dental insurance plans and coverage. Regardless of the dental benefits plan, there are usually three parties involved: you, the patient; the dentist providing care; and a third party with whom you or your employer contracts for coverage. If your options include a plan funded by your employer, you may have an administrator responsible for processing and payment of claims.
The primary responsibility of the third party is to provide the financial foundation for your dental benefits plan. There are three types of third parties:
Third Parties Often Limit Your Freedom to Select the Dentist Right for You
Without question, the best method of choosing a dentist is by reviewing the doctor's qualifications, visiting the office to make sure it is clean & modern, and interviewing the doctor for compatibility with your needs. As an educated consumer, you are the best person to decide which dentist is right for you.
Dental benefits plans can be categorized by the options offered for selecting a dentist. Some plans allow you the freedom to choose your own dentist, while others, in exchange for lower rates, limit your choice. These two alternatives are called open and closed panel plans.
The participating dentists agree to charge less than usual fees to this specific patient base, providing savings for the plan purchaser. Dentists are able to do this by placing limitations on the time they spend with patients, the types of procedures they offer, and the methods or materials used. The savings comes from providing a lower level of care.
How Insurance Benefits Get Paid
When choosing a benefits plan, it is important to know who pays what to whom. Dental plans can be categorized into three types, based on the compensation method and treatment provided:
How Benefit Coverage is Calculated
A clear understanding of the methods used to calculate benefits and payments would allow you to compare and evaluate the purchasing power of different plans. Insurance companies don't make this simple. They use a system based on payment schedules to calculate benefits. Insurance payment schedules are created by insurance companies. Don't confuse the insurance terminology for "payment schedule" with the actual fees charged by dental offices - these are two different things. The following are four common payment schedule schemes used:
Dental Plans Have Limitations and Exclusions
Today's health insurance, including your dental plan, is designed to help you get the care you need at a reasonable cost. Because each person's oral health is different, costs can vary widely. To control dental treatment costs, most plans will limit the amount of care you can receive in a given year. This is done by placing a dollar limit or "cap" on the amount of benefits you can receive, and by restricting the number or type of services that are covered. Some plans may totally exclude certain services or treatment to lower costs. Know specifically what services your plan covers and excludes.
There are also certain limitations and exclusions in most dental benefits plans that are designed to keep costs from going up. All plans exclude experimental procedures. Many plans consider innovations in dentistry to be experimental, long after they have become widely accepted by the dental profession. Plans usually exclude services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes dental coverage and health insurance may overlap. Exclusions in your dental plan may be covered by your medical insurance. The only way to understand limitations and exclusions is to read and understand the conditions of your dental plan (usually in the tiny print).
Consumers are encouraged to choose plans that impose dollar or service limitations, rather than those that exclude categories of service. By doing so, you can receive the care that's best for you and actively participate with the dentist in the development of treatment plans that give the most and highest quality care.
Other Tricks to Reduce Claims Payments
Insurance carriers use a variety of other methods to reduce their payment of dental claims. Most plans also provide patients and purchasers with special administrative services that are helpful in limiting payouts. Find out if your plan uses any of the following mechanisms to help you analyze and dispute, if necessary, coverage for your dental care.
Factors to Consider When Choosing or Using Your Dental Plan
What looks like a bargain today may not be a good buy in the long run. While your out-of-pocket costs are, of course, an important part of your decision-making process when choosing a dental plan, they are not the only criteria to use when evaluating your options. Your primary focus should be to determine whether the coverage would satisfy your dental care needs. If you have a choice of whether to purchase dental insurance coverage or not, you might be better off paying for your care directly and forgoing the expense of dental insurance premiums and the minimal reimbursement of submitted insurance claims. Consider the following:
Does the plan give you the freedom to choose your own dentist or are you restricted to a panel of dentists selected by the insurance company?
If you have a family dentist with whom you are satisfied, consider the effects changing dentists will have on the quality or quantity of care you receive. Because regular visits to the dentist reduce the likelihood of developing serious dental disease, it's best to have and maintain an established relationship with a dentist you trust.
Who controls treatment decisions -- you and your dentist or the dental plan?
Many plans require dentists to follow treatment plans that rely on a Least Expensive Alternative Treatment (LEAT) approach. If there are multiple treatment options for a specific condition, the plan will pay for the least expensive treatment option. If you choose a treatment option that may better suit your individual needs and your long-term oral health, you will be responsible for paying the difference in costs. It's important to know who makes the treatment decisions under your plan. These cost control measures may have an impact on the quality of care you'll receive.
the plan cover diagnostic, preventive and emergency services?
|Restorative care||amalgam and composite resin fillings and stainless steel crowns on primary teeth|
|Endodontics||treatment of root canals and removal of tooth nerves|
|Periodontics||treatment of uncomplicated periodontal disease including scaling, root planing and management of acute infections or lesions|
|Oral surgery||tooth removal (not including bony impaction) and minor surgical procedures such as tissue biopsy and drainage of minor oral infections|
|Prosthodontics||repair and/or relining or reseating of existing dentures and bridges|
Understand what routine dental care is covered by the plan, and what percentage of the costs will come out of your pocket.
Since dental benefits encourage you to get preventive care, which often eliminates the need for major dental work, most plans are not generous when it comes to paying for major dental work. Many plans cover less than 50 percent of the cost of major treatment. Most plans limit the benefits -- both in number of procedures and dollar amount -- that are covered in a given year. Be aware of these restrictions when choosing your plan and as you and your dentist develop treatment best suited for you. Major dental care is often defined (by the insurance companies) to include:
Restorative care gold restorations and individual crowns Oral surgery removal of impacted teeth and complex oral surgery procedures Periodontics treatment of complicated periodontal disease requiring surgery involving bones, underlying tissues or bone grafts Orthodontics treatment including retainers, braces and/or diagnostic materials Dental implants either surgical placement or restoration Prosthodontics fixed bridges, partial dentures and removable or fixes dentures
Some plans limit referrals to specialists. Your dentist may be required to refer you to a limited selection of specialists, who have contracted with the plan's third party. Specialists who have contracted with the insurance company may make compromises in the treatment procedures offered, so many specialists are not participating in insurance plans. You also may be required to get permission from the plan administrator before being referred to a specialist. The insurance companies use the term "plan administrator" to describe their clerical employees assigned to this task, these people do not have professional credentials.
If you choose a plan with these limitations, make sure qualified specialists are available in your area. Look for a plan with a broad selection of different types of specialists. If you have children, you may prefer a plan that allows a pediatric dentist to be your child's primary care dentist.
Since specialized treatment is generally more costly than routine care, some plans discourage the use of specialists. While many general practitioners are qualified to perform some specialized services, complex procedures often require the skills of a dentist with special training. Discuss the options with your dentist before deciding who is best qualified to deliver treatment.
Dentists participating in closed panel or capitation plans may have select hours to see plan patients. They may schedule appointments for these patients on given days, or at specified hours of the day, restricting your access. Plan patients might not even be seen for certain weeks each month.
Some dentist's fees for seeing plan patients on weekends or during emergencies are higher than the plan coverage. You may be required to pay additional costs yourself.
If you select these types of plans, have a clear understanding of your dentist's policies as well as the plan's dentist-to-patient ratio. It's the best way to ensure your access to care is not unduly restricted and that you are not surprised by higher fees the plan does not cover.
It is not unusual to be eligible for dual benefits. You may be covered under your company's plan as well as under that of your spouse's employer. In analyzing your options, make sure to look for a plan that allows coordination of benefits. You should be entitled to either 100 percent coverage or some form of premium credit. By coordinating benefits, you can eliminate being penalized or denied coverage when the two plans have conflicting exclusions.
To take full advantage of your dental benefits plan, visit the dentist regularly and get the preventive care that will keep your mouth healthy. Insurance coverage is always better for preventive care than for treatment. Do your dental homework -- brush and floss regularly and maintain a regular schedule of oral examinations and teeth cleanings.
Follow the treatment plan you and your dentist have developed. Your doctor should be more interested in your health than your insurance coverage - the doctor is supposed to help you select appropriate treatment options suited to your condition and your personal desires (without regard to what the insurance company wants to cover).
Should you need treatment for particular conditions, follow the procedure for predetermination required by your plan. Find out what your insurance will cover. Feel free to discuss a payment plan with your dentist for your portion of the treatment costs.
Federal law mandates that consumers with dental coverage receive a fully detailed patient information handbook -- a Description of Benefits -- that clearly outlines coverage, limitations and exclusions. Before selecting a plan that best suits your needs, ask your carrier or company benefits coordinator for a copy of the benefits handbook. If you have questions about coverage, exclusions, calculation of benefits or payment of benefits, ask before making your plan selection. Find out which plans your dentist participates in and why. That's the best way for you to get care from the dentist of your choice, and still take advantage of the cost savings due to you.
While no insurance plan is perfect, having the facts to make an informed decision can make a difference. Each plan has its advantages and limitations. Read the fine print. And by all means ask questions. It pays to be a educated consumer.
Don't make the mistake of letting your insurance policy or carrier make treatment decisions for you - use the advice and recommendations of a carefully selected, trusted dentist to help you make your own decisions about what treatment is best for you.