What is dental insurance? Dental insurance, sometimes called a dental plan, is a form of health insurance designed to pay a portion of the costs associated with dental care offered in dental clinics. Dental insurance is often provided in conjunction with vision insurance, with both types of care covered under a single plan. Dental insurance companies have fee schedules that are generally based on usual and customary dental services, an average of fees in an area. The fee schedule is commonly used as the transactional instrument between the insurance company, dental office, dentist, and the consumer (patient). Dental Plan Categories Although the features of plans may differ, they can be grouped into the following categories: Direct reimbursement programs They pay patients a predetermined percentage of the total amount they spend on dental care, regardless of the type of treatment they opt for. 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 sound solutions. Usual, customary, and reasonable (UCR) programs They 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 "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. Table or schedule of allowance programs They 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 They pay contracted dentists a fixed amount (usually every month) per enrolled family or patient. In return, the dentists agree to provide specific types of treatment to the patients at no charge. 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. The following options are present: Preferred Provider Organization (PPO): Preferred Provider Organization, or PPO, is a network of healthcare providers that provide its members with multiple choices regarding healthcare and healthcare providers. PPOs do not restrict patients to receiving care in-network. It’s optional to designate a primary care physician. Patients can make appointments directly with the providers, and referrals aren’t required. Usually, PPO plans provide better benefits and lower costs for services availed from network providers, which covered persons are encouraged to use. However, members can also receive care from providers outside of the network, although they will likely pay more for it. Dental health maintenance organization (HMO): A Health Maintenance Organization, or HMO, is a network of healthcare providers who agree to provide services at lower prices worked out by an insurance company. Members choose a single physician from a list of approved healthcare providers. HMO members can only see a health care specialist such as an obstetrician, rheumatologist, or cardiologist if they get a referral from their Primary Care Physician (PCP), who is also known as the gatekeeper. Various services and benefits provided by an HMO can differ depending on the company and the health plans. It may cover health screenings, cancer screening, prescribed medications, laboratory tests, X-rays, and other scans. HMOs usually cover prenatal care and baby care also. What do these policies 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. 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 100-50 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.

Differences between HMO and PPO Provider Networks A network is a group of healthcare providers that are under contract with insurance companies to offer discounted services for a particular HMO or PPO plan. They typically include general physicians, along with specialists such as dermatologists and chiropractors. To receive coverage in an HMO, you must first see your PCP, no matter what the problem is. If they can't treat you, they will refer you to someone else within the network. Staying within your network in an HMO plan, you can expect maximum insurance coverage. Go outside of the network, and your coverage vanishes. With a PPO, you can visit doctors outside the network and still get some coverage, but not as much as you would if you remained in the network. Cost Analysis With a PPO, the trade-off for receiving the freedom of choice and flexibility in higher premium costs for the plan. An HMO offers no coverage outside the network, but patients enjoy lower premium costs. Claims Forms With an HMO, patients do not need to file a claim because healthcare providers are paid directly by the insurance company. Under PPO, however, patients must sometimes first pay out-of-network providers and then file a claim for reimbursement from the insurance company. Services Covered The range of services provided under the two plans depends on the company and the type of plan taken, but they are usually similar. Prescriptions Just like the coverage under an HMO is limited to a network, the pharmacy locations where one can get their prescriptions filled and covered under the plan are limited as well. PPOs allow patients to fill a prescription almost anywhere but with additional charges for an out-of-network pharmacy. Exceptions Patients with an HMO plan do not need a referral during an emergency or for in-network visits to a gynecologist or obstetrician. FAQs What treatments does my dental insurance cover? Most standard dental insurance plans cover basic services such as teeth cleanings, fillings, dental examinations, and X-rays. More comprehensive plans may also offer full or partial coverage for treatments such as crowns, veneers, teeth whitening, and dentures. Can my dentist create a treatment plan based on my insurance plan? The main priority for all dentists is to make sure you get the proper care. Your treatment plan will be based on your dental health needs, not on what your insurance covers. If your dentist provides you with multiple options, then you can ask about different cost estimates and possible treatment outcomes.