Full coverage dental insurance can be confusing. People tend to think that this insurance term guarantees that they don’t ever have to pay for dental treatments. But this is not always the case since some companies may charge certain fees in...
What every informed consumer needs to know...
If you’ve ever had dental work done, particularly major procedures such as crowns or implants, then you know that it can be very expensive. If you don’t have access to dental insurance through your job, you may have to purchase it on your own.
However, like with all insurance, knowing whether or not you need dental insurance is all about weighing the risk. Individuals who take fantastic care of their teeth and aren’t prone to specific dental conditions may find that it’s much cheaper to just pay for checkups and annual deep cleanings out-of-pocket instead of paying the same amount for dental insurance. However, if you require additional procedures beyond routine preventative care, dental insurance can really help you save. This overview, we'll show you what you should know about dental insurance and how to pick a policy that will fit your needs.
Most dental insurance plans have coverage that breaks down into four distinct classes, based on the necessity, severity and complexity of the work needed. Your portion of the cost of dental care depends on which class the procedure is categorized as by your insurance provider. Outlining dental insurance coverage can be confusing, because a dental procedure may be considered Class I under one provider’s policies, but be considered a Class II or III by another. Let’s take a look at how these service classes usually break down.
Class I (Preventive Care): This would include basic preventive dental care measures, such as periodic exams, general cleaning, deep cleaning, X-rays, sealants (sometimes dependent upon age), and fluoride treatments. This type of care is 100% covered by most of the Top 10 insurance providers, with up to two visits per year.
Class II (Basic Procedures): Common examples of Class II procedures would be fillings, tooth extractions, root canals, anesthesia and Periodontics (gum disease treatment). However, root canals for example are considered a Class III procedure by about half of the Top 10 companies, so if you are prone to certain dental issues, it’s critical to make sure you know how that particular treatment is covered. How much of the cost will be covered also depends on the provider and how the procedure is categorized, but basic procedures are commonly 80% covered (after the deductible) by the insurance company.
Class III (Major Procedures): Common major procedures would be crowns, bridges, dentures (partial or complete), extensive oral surgeries, and any necessary implants. But again, some of these could be classified as Class II, dependent upon how it’s outlined by each specific plan or insurance provider. Major procedures are usually 50% covered by insurance, which means that is potentially a lot of out-of-pocket money wasted or saved, based upon your specific situation and dental history.
Class IV (Orthodontia): Orthodontic care involves the use of devices, such as braces, to correct abnormalities of the teeth and jaw. This type of coverage is highly variable by provider, and there is usually an age limit in place (commonly dependents age 19 and younger are eligible). Check with specific insurance companies for more information on orthodontia coverage.
Dental Insurance Procedures by Class
Another important factor to research would be any benefit limits on the insurance. With both high and low-end dental plans, there is almost always an annual maximum payout per-person, per-benefit period (usually January through December).This means that once the maximum amount has been reached, any additional dental care costs will need to be paid out of pocket until the begining of the new policy year. The annual maximum varies based on the provider and the plan you select. The common range is about $1,000 to $1,500, but it can be higher or lower. Many companies offer multiple plans, and the plans with higher premiums tend to also have higher annual maximum payouts.
Dental insurance providers also usually have waiting periods in effect for coverage. Most of the Top 10 insurance companies have no waiting period before Class I, or preventive, dental care will be covered. A 12-month waiting period for coverage on Class III procedures is common, but many companies also have waiting periods before Class II coverage takes effect, usually ranging from three to six months. However, a few companies have no waiting periods at all.
This is why it’s important to inquire about the waiting periods before selecting a plan, rather than finding out later that you need to have an immediate procedure take place, but it’s not covered for another three months. Any and all benefit limits will be outlined in the service contract, so read it carefully before purchasing any insurance.
Dental Insurance Benefit Limits & Waiting Period Comparison
Dental insurance typically comes in the form of three different plan options: dental health maintenance organization (DHMO), preferred provider organization (PPO, also referred to as a participating dental network, or PDN), or an indemnity plan. Most of the Top 10 insurance companies offer DHMO and PPO plans, and all but one of them offer indemnity plans as well. You should select a plan based on the providers (dentists) you want to choose from, and what you can afford to pay.
Dental Health Maintenance Organization (DHMO): A DHMO tends to be a lower-cost benefits and insurance plan. You are required to choose one dentist or dental facility as your primary care provider, and you must choose from in-network providers only. A typical DHMO plan doesn’t have any deductibles or maximums. You pay a fixed dollar amount for any covered treatment, which is a copay. However, if the procedure is not covered by a copay, you are responsible for all of the cost. All care must be administered by your primary care provider, otherwise the procedure won’t be covered. If you take good care of your teeth and don’t need to use insurance very often, this is often the most cost-effective plan because you pay lower premiums and don’t have to pay a deductible. However, should something drastic and unexpected happen to your teeth, you could be stuck with the entire bill.
Preferred Provider Organization (PPO): Dental PPO plans offer the freedom to visit any licensed dentist to receive benefits, but you will typically enjoy lower costs if you choose an in-network dentist. Services are rendered based on your deductible amount and your coinsurance percentages, in addition to your monthly premiums. These plans can cost more in the long-run than a DHMO plan due to the higher premiums, but you’re offered more comprehensive dental care.
Indemnity: Also known as a fee-for-service option, these plans offer the greatest choice of dentists, as you can visit any dentist you want. Like PPO plans, you typically pay a deductible, and then a fixed percentage for each service and the plan pays the rest. However, participating PPO providers usually offer discounts on procedures not covered by your plan. You do not have this option with an indemnity plan, so it’s possible you’ll end up paying more in addition to the high premiums.
With all three of these plans, how well it will work for you can depend on how many in-network providers the company boasts where you live. Most of the Top 10 companies have over 100,000 network locations, which gives you the freedom of choice. Companies with smaller networks will likely have fewer options if you live in an area where their network is lacking, which is why it’s important to inquire about network providers before choosing a plan.
Additionally, dental insurance providers a often have plans for individuals, couples and families if you are looking to cover other members of your family.
Dental Insurance Plan Comparison
When selecting a dental insurance provider, you should also consider their customer service. Insurance can be complicated and difficult to understand, which is why it’s important that providers make it as easy as possible for their customers. For example, most of the Top 10 companies will pay your dental care provider directly, which means you won’t have to worry about paying the bill upfront and waiting for reimbursement. Once the dental insurance company has paid their portion, you’ll receive a bill with your portion of the remaining balance.
Most companies now offer an online customer portal, which you can use to submit and track any open claims, or to review and refer to previous claims you may have had. Through this portal you can also communicate with a representative regarding any questions or concerns you may have. This is often done through email or a phone number you can call, but some insurance agencies also have live chat functionality, which means you can get connected to a representative on the spot and have your needs addressed through the chat box.
If you prefer other methods of communication or claims submission, such as mail or fax, most of the insurance companies still allow that option. But be sure to inquire specifically, because this could be restricted to certain items or procedures. Do some solid research into a company’s customer service record before committing, because a company that values their customer’s time and money as much as their own should be respected.
Dental Insurance Customer Service Comparison
The total cost you wind up paying for dental insurance varies greatly, as there are many factors that go into what you pay. For example, there are dental insurance premiums you may be responsible for, which is a fixed monthly cost. This is an easily predictable expense that you can budget for, as monthly premiums usually fall somewhere in the $25 to $50 per month range for individual plans. The other costs, however, are not as straight-forward.
Deductibles, coinsurance and copays are all examples of costs that depend on how and when you use your insurance. A deductible is the amount you pay for dental care services before your insurance kicks in. Let’s say your plan’s deductible is $100. That means for most services, you will pay all costs until the amount reaches $100. After that, you share the cost by paying coinsurance and/or copays.
Coinsurance is your share of the costs of a dental service. As we outlined earlier, Class I services are 100% covered by most of the top 10 insurance companies. However, with Class II and III procedures, you are responsible for a certain percentage of the costs that exceed your deductible. For example, if you have a root canal performed and that procedure qualifies for 80% coverage from the insurance company, the other 20% is your responsibility. This is your coinsurance, and that amount varies greatly based on the extent of the services performed.
Some plans also have copays instead of, or in addition to, coinsurance. A copay is a fixed amount you pay for a dental care service. This is usually paid when you receive the service, and it’s paid directly to the dental care provider. If you go in for a checkup, you may be responsible for a copay, which usually ranges from $15 to $30, but it may be more like $250 for a visit to an emergency clinic. Copays are usually paid per-office visit, but this really only applies to DHMO plans. PPO and indemnity plans usually only have deductibles and coinsurance in addition to your premiums.
With so many dental insurance options to choose from, reading reviews from consumers who have experience with these companies can be a great way to help you decide. Here are a few things to look for when looking over reviews.