Dental Insurance: Whats Covered, Whats Not

If you have dental benefits, do you know what’s in the fine print and what type of plan is best for you?

Many Americans -- 77% -- have dental benefits, the National Association of Dental Plans says. Most people have private coverage, usually from an employer or group program. Large employers are more likely to offer dental benefits than small employers and high wage workers are more likely to receive them than low wage workers. Medicare doesn’t cover dental care, and most state Medicaid programs cover dental care only for children.

To make the most of your benefits, you need to know these things.

Insurance or Benefits?

When shopping for insurance, you may see the term dental benefits, which is different from insurance.

An insurance plan is meant to absorb risk -- the risk that you’ll need to have a tooth pulled, for instance, or to get a root canal -- and covers costs accordingly.

A benefits plan covers some things in full, but other things only partially, and others not at all. It’s meant to be helpful, but it’s not a catch-all.

When you shop for coverage, make sure you understand what the plan covers.

Dental Plan Categories

Although the features of plans may differ, the most common designs can be grouped into the following categories:

• Direct reimbursement programs pay patients a predetermined percentage of the total amount they spend on dental care, regardless of treatment category. This method typically does not exclude coverage based on the type of treatment needed, allows patients to go to the dentist of their choice, and encourages them to work with the dentist toward healthy and economically sound solutions.
• "Usual, customary, and reasonable" (UCR) programs usually allow patients to go to the dentist of their choice. 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. Although these limits are called "customary," they may or may not accurately reflect the fees that area dentists charge. There is wide fluctuation and lack of government regulation on how a plan determines the "customary" fee level.
• Table or schedule of allowance programs determine a list of covered services with an assigned dollar amount. That amount represents just how much the plan will pay for those services that are covered, regardless of the fee charged by the dentist. The difference between the allowed charge and the dentist's fee is billed to the patient.
• Capitation programs pay contracted dentists a fixed amount (usually on a monthly basis) per enrolled family or patient. In return, the dentists agree to provide specific types of treatment to the patients at no charge. (For some treatments, there may be a patient co-payment.) The capitation premium that is paid may differ greatly from the amount the plan provides for the patient's actual dental care.

Types of Plans

Dental plans are similar in some ways to health insurance plans in some respects, but different in other ways. You’ll generally have the following options:

Preferred provider organization (PPO): As with a health insurance PPO, these plans come with a list of dentists that accept the plan. You have the option of going out of network, but your out-of-pocket costs will be higher.

Dental health maintenance organization (DHMO): Like a health insurance HMO, these plans provide a network of dentists that accept the plan for a set co-pay, or no fee at all. However, you may not be able to see an out-of-network dentist.

Discount or referral dental plan: This is a plan in which you get a discount on dental services from a select group of dentists. Unlike health insurance, the discount or referral plan doesn’t pay anything for your care. Rather, the dentists who participate agree to give you a discount for the care you receive.

Understanding Dental Insurance Plans

Predetermination of costs

Some dental insurance plans encourage you or your dentist to submit a treatment proposal to the plan administrator before starting. The administrator may determine your eligibility, the eligibility period, services covered, your co-payment, and the maximum limitation. Some plans require predetermination for treatment over a specified dollar amount. This is also known as preauthorization, precertification, pretreatment review, or prior authorization.

Annual benefits limitations

To help contain costs, your dental insurance plan may limit benefits by the number of procedures or dollar amount in a given year. In most cases, especially if you've been getting regular preventive care, these limitations allow for adequate coverage. By knowing what and how much the plan allows, you and your dentist can plan treatment that will minimize out-of-pocket expenses while maximizing compensation offered by your benefits plan.

Peer review for dispute resolution

Many dental insurance plans have a peer review mechanism through which disputes between third parties, patients, and dentists can be resolved, eliminating many costly court cases. Peer review aims to ensure fairness, individual case consideration, and a thorough examination of records, treatment procedures, and results. Most disputes can be resolved satisfactorily for all parties.

What They Cover

Generally, dental policies cover some portion of the cost of preventive care, fillings, crowns, root canals, and oral surgery, such as tooth extractions. They might also cover orthodontics, periodontics (the structures that support and surround the tooth) and prosthodontics, such as dentures and bridges. You’re usually covered for two preventive visits per year. Further reading: Does dental insurance cover teeth straightening?

If you get an individual policy, periodontics and prosthodontics may not be available in the first year of coverage. And orthodontics often requires a rider, in which you pay an additional fee, for any kind of policy.

Most plans follow the 100-80-50 coverage structure. That means they cover preventive care at 100%, basic procedures at 80%, and major procedures at 50%, or a larger co-payment. But a dental plan may elect not to cover some procedures, such as sealants, at all.

Limitations of Dental Insurance Plans

Every plan has a cap on what it will pay during a plan year, and for many that cap is quite low. This is the annual maximum. You pay all expenses that go beyond that amount. About half of dental PPOs offer annual maximums of less than $1,500. If that’s your plan, you’d be responsible for all expenses above $1,500. If you need a crown, a root canal, or oral surgery, you can reach the maximum quickly.

There’s generally a separate lifetime maximum for orthodontics costs.

Some plans may totally exclude certain services or treatment to lower costs. Know specifically what services the plan covers and excludes.

But there are certain limitations and exclusions in most dental insurance plans that are designed to keep dentistry's costs from going up without penalizing the patient. All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes, dental coverage and medical health insurance may overlap. Read and understand the conditions of your dental insurance plan. Exclusions in your dental plan may be covered by your medical insurance.

Timing

Experts generally encourage adults to see their dentists twice a year. Dental benefits policies support this, although the wording varies. It may be that your policy will pay for a preventive visit every 6 months (but no closer together), or twice per calendar year, or twice in a 12-month period. Get to know your policy so you understand how it works. That will help you schedule your appointments.

There are usually time limits on other services as well, such as X-rays, fillings on the same tooth, crowns and bridges on the same tooth, or fluoride treatments for children. For instance, your policy may pay for a full series of X-rays only once every 3 years.

Preexisting Conditions

You may not be able to find a dental plan that covers conditions that exist before you enrolled. If that’s the case, you will have to pay any ongoing treatment costs out of pocket.

What to Do Before a Procedure

Read your dental policy closely to see whether your procedure is covered. Call your insurance company if you have questions.

If you need a major procedure, you can ask your dentist to submit a pre- treatment estimate. This will help you know what you’ll likely owe after any coinsurance, deductible, and policy maximum.

It’s also smart to understand how your dental plan handles emergencies. Many have provisions for urgent care or after-hours care, but you may owe a deductible, a copay, or a larger percentage of costs.

What to Consider

If your employer offers dental coverage, that’s an easy choice. It tends to be cheaper than getting a policy on your own. If you’re shopping for your own plan and you already have a dentist, your dentist may be able to recommend a plan based on your dental history.

As you compare plans, try to find out the following things:

• Whether your dentist and any specialists you may need are in network
• Total costs for the plan each year, including premiums, co-pays, and deductibles
• Annual maximum
• Out-of-pocket limit, if any
• Limitations on pre-existing conditions
• Coverage for braces, if needed or anticipated
• Emergency treatment coverage, including treatment if you’re away from home
• Whether you can choose your own dentist
• Who controls treatment decisions: you and your dentist, or the dental plan
• Whether the plan covers diagnostic, preventive, and emergency services, and how much
• What routine treatment is covered
• What major dental care is covered
• Whether you can see the dentist when you need to and schedule appointment times convenient for you
• Who is eligible for coverage under the plan, and when coverage goes into effect

Patients and dental insurance plan purchasers should insist on regular reviews of premium levels to make sure that UCR or table of allowances payment schedules are equitable. This analysis can help optimize your benefit levels, making sure that every dollar you spend is used wisely.

If you are covered under two dental benefits plans, tell the administrator or carrier of your primary plan about your dual coverage status. In some cases, you may be assured full coverage where plan benefits overlap and receive a benefit from one plan where the other plan lists an exclusion.

It may be best to choose a plan with dollar or service limitations, rather than one that excludes categories of service. By doing so, you can get the care that's best for you and work with the dentist to develop treatment plans that give the most and highest-quality care.

Your dentist can’t answer specific questions about your dental insurance plan or predict what level of coverage for a particular procedure will be. Each plan and its coverage vary, according to the contracts negotiated. If you have questions about coverage, contact your employer's benefits department, your insurance plan, or the third-party payer of your health plan.

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