Dental Insurance – What You Need to Know

Dental insurance is an important part of many people’s overall health care plans. There are several different types of individual and family dental coverage available, including indemnity plans, Preferred Provider Network (PPO) options and Dental Health Managed Organizations (DHMO).

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Choosing a plan requires understanding cost-contributing elements like deductibles, copayments, annual maximum benefits and monthly premiums.

Coverage Options

Generally, dental insurance comes through an employer-sponsored plan or from your state’s health exchange. It’s also possible to purchase individual dental plans through insurers directly, but that option tends to carry higher premium rates than those available with group plans.

When shopping for dental coverage, look at premiums, annual maximums and deductibles before making a decision. Also consider waiting periods (generally required only for major work), as well as the number and types of procedures covered.

Some policies require you to stay within the plan’s provider network to get help paying for your care. Others allow you to see any dentist, though the percentage of costs paid by your insurance may be less than if you were in-network.

Most insurers have a provider database that’s easy to use online. You can search for your preferred dentist or specialist to verify that they’re part of the insurer’s network before you enroll. You can also check a policy’s summary to see whether it lists “basic” or “major” coverage for various procedures. If the insurer designates a procedure as basic, you can choose a plan with lower annual limits and lower premium rates.

Preventive Care

The vast majority of dental issues can be prevented by regular visits to the dentist. Dental insurance focuses on preventive care with 100% coverage for cleanings, exams and fluoride treatments, reducing the need for more costly major services down the road.

Many employers offer group dental insurance as a part of an employee benefits package, but you can also purchase individual or family plans directly from dental insurers. You will typically pay a monthly premium, which is often deducted from your paycheck. Some plans have an annual maximum, meaning the amount your plan will cover toward most dental procedures within a benefit period, and others have lifetime maximums.

Some dental insurance plans are indemnity plans that allow you to go to any dentist and get reimbursed a set amount, usually based on what is called the Usual and Customary fee for the procedure. Others are Preferred Provider Network (PPO) or Dental Health Maintenance Organization (DHMO) plans that have a network of dentists that agree to offer services at a discounted rate for plan members.

Out-of-Pocket Costs

The cost of dental insurance varies depending on factors like how many people are covered, where they live and whether they choose to use in-network or out-of-network providers. The premium, or monthly fee, is also a major factor when comparing plans.

Generally, there is a deductible that must be met before the dental plan starts paying for services. This is usually a set dollar amount, such as $100, and it is applied per service. After the deductible is met, most dental insurance plans will cover a percentage of the cost, for example 20% or 80%. This is called coinsurance and the amount you pay will be stated on your policy card.

There is also a limit on the amount that the insurance company will pay in a year, called an annual maximum. This is often reached quickly with procedures like orthodontia, so it is important to know this limit before selecting a dental insurance plan. Dental HMOs, which are similar to health insurance HMOs in that patients designate a primary care dentist who manages their access to specialists, typically have the lowest out-of-pocket costs as they only cover services received from in-network providers.

Deductibles and Copayments

Most dental insurance plans have a deductible that you must pay out-of-pocket before the plan starts paying for procedures. Deductibles are typically based on a calendar year (though some plans may roll annually depending on when you signed up) and must be met before the insurance company begins paying a percentage of your care. In addition, some plans have copays that are set dollar amounts you must pay at the time of each visit.

Generally, dental Preferred Provider Organization (DPPO) and Dental Health Maintenance Organization (DHMO) plans have the lowest costs when you use in-network providers. However, DPPO and DHMO plans limit your options by only covering care from approved providers and may require referrals to see specialists.

A dental discount plan is a different type of coverage that provides lower costs for preventive care but does not cover basic treatment, like fillings and root canals. Most dental discount plans cost less than a dental PPO but more than an indemnity plan. eHealth’s licensed insurance agents can help you compare plans and prices to find the best fit for your budget and needs.

Waiting Periods

Dental insurance waiting periods are a part of the policy that limit when you can get coverage for specific procedures. They often apply to basic and major services. Typically, these include fillings, stainless steel crowns and dentures, among others. Generally, preventive care doesn’t have a waiting period; however, that can vary by plan.

Waiting periods are a way to ensure that people don’t purchase a dental plan, quickly get expensive work done and then cancel the plan. This helps to control costs for the insurance company as well.

The length of a waiting period can range from a few months to up to a year. Dental insurance discount plans often don’t have a waiting period.

If you are looking for a dental plan to replace an existing one or transition from an employer-provided option because of a job change, try reaching out to the insurer to see about waiving the waiting period. This can be easier if you have been covered before, such as through an employer or previous coverage from another provider.