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INTRODUCTION

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The world of dental insurance can feel deliberately complicated, even to those who deal with it daily. We created this page in an attempt to add some clarity and dispel myths. You can find definitions of basic insurance terms below.

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IF YOU GET NOTHING ELSE FROM THIS PAGE, KNOW THIS: "Dental insurance" is not really insurance at all. Most insurances (i.e. auto, home, medical, life, ...), are intended as a safety net for financial hardships. DENTAL IS NOT. Dental insurance typically covers a portion of day-to-day, relatively minor, dental expenses, but caps-out and leaves you uninsured for major expenses as a result of the extremely modest yearly limits, known as "maximums".   For this and reasons below, only 50% of our patients have dental coverage.

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Insurance will never pay over the yearly "maximum". "Maximums" were typically $1000 per year in early 1970's, when cleanings were $6.  Most plans today still have maximums of $1000-$2000.  Maximums should be $9000+ per inflation. Every January, we see insured patients utilize their yearly maximum on treatment for one tooth, and thus they are uninsured for the remainder of the year.  And keep in mind, usually anything paid by insurance comes out of the maximum, so after yearly preventive care, a $1000 may only leave you with $600.  

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FAQ's

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CAN YOU RECOMMEND A PRIVATELY OBTAINED INSURANCE PLAN?

Privately obtained plans are significantly inferior to group plans that large businesses have access to. There has never been a privately obtained dental plan that made financial sense.  Here are some of the reasons:

• Many are HMO's, which means you have to visit a contracted clinic and cannot choose your dentist.

• Many privately obtained plans typically pay based on what is called a "fee schedule",  which is a set amount, usually less than 50% of the average dental fee. You pay the remainder.

• Premiums usually over $500 per year per person with yearly maximum of $1000.

• Waiting periods (though some attempt to imply there are no waiting periods where there actually are).

WHY WE ARE NOT IN YOUR NETWORK?

Unlike general medicine, being in dental networks is very uncommon.  95% of dentists do not participate in HMO's, and a very high percentage are not in any PPO networks because of the limitations plans impose.  Some dentists may be in one or two PPO networks out of the dozens that exist. We do not believe  that HMO offices can provide anywhere near our level of care.  I am not comfortable with a system which provides discounted care in exchange for a larger volume of patients, or creating different levels of care. As a consumer, I advise you not utilize plans that limit your choice of dentist.

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WHY ARE SOME PROCEDURES NOT COVERED?
Benefits covered by a dental plan have been negotiated between the employer and the insurance company. Unfortunately even if a proceedure is the only option, if it is not a covered benefit the insurance will not pay.

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WHY DID MY INSURANCE NOT PAY FOR A PROCEDURE THAT IS COVERED?
Insurance companies have the right to decide whether to pay. This is a very sticky issue, and the source of much frustration. A procedure may be denied because of frequency, having hit your yearly maximum, or due to other contractual fine print that the dental office and patient has no access to.  You are always welcome to dispute an insurance company's decision, but a dental office has limited avenues.

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IF I DON'T HAVE DENTAL INSURANCE, WHAT HAPPENS IF I GET IN AN ACCIDENT?
Don't confuse the need for medical insurance with dental. The yearly maximum is always the limiting factor. No matter what dental care you require, your insurance will not pay more than that maximum. If you have dental insurance just for a rainy day, you might want to look at your premiums and keep in mind the yearly maximum.

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IF I HAVE 100% INSURANCE COVERAGE, SHOULD I HAVE TO PAY ANYTHING?
Almost no one has 100% coverage for everything.  Some plans have 100% coverage for certain procedures, like preventive, but beyond that, if the plan states 100%, it is likely100% of the insurance company's internal "fee schedule", which is always far below the real-world fees.

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I'M TOLD THAT I NEED MY TEETH CLEANED EVERY 3 MONTHS, BUT MY INSURANCE WILL ONLY PAY FOR 2 PER YEAR.
Your plan is simply a contract of benefits negotiated by your employer and your insurance company for all employees. Many plans only cover two hygiene visits per year regardless of what your health necessitates.  

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REAL WORLD EXAMPLES

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Federal Government Employee Example

Many years ago I asked by a close friend to help choose between 2 dental insurance plans offered by her employer, the Veterans Administration.  Keep in mind these figures are very old, but the outcome today would be the same. One plan ($120/year) was an HMO and thus she would have to go to one of those clinics to use her plan, so that was off the table.  The second plan, a PPO through Delta Dental, ($240/year, $1000 maximum) allowed her to go to any dentist. That was out an unfavorable option, but lets see why:

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This PPO plan paid based on a fee schedule. 2 cleanings, checkup x-rays, and 1 exam, they only paid $94.  At that time, those yearly preventive procedures cost $215.  My friend would pay $240 in premiums plus the $121 (215 minus 94) the plan didn't cover, costing her $341/year for only $215 in services.  Then if you look at what they paid for fillings and other procedures, the plan made even less sense.  I was pleased to hear that the word around the VA was not to elect for either dental plan and just be a cash-paying patient. She continues to pay out of pocket for dental services, saving money every year.

Private Sector Example

A major pharmaceutical company offers its employees 3 dental plans (table below). None of the 3 plans have a deductible and you may choose any dentist (i.e. PPO).

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To choose from these 3 plans I start with the fact that minimum preventive services per year at that time cost about $215 and that all 3 plans pay 100% of this.  Thus you certainly save money with the "Preventive" plan ($111/year premium).  

If you pay $129/year more for the "Standard" plan to add the 50% benefit for basic & major, it means to get that $129 you spent back from the insurance company  you need $258 in basic &/or major dental work on the average each year because they only cover 50% of it.  If you rarely need more than cleanings you may want to stick with the "Preventive" plan.  

For my friend, I recommended the "Comprehensive" plan because she has had dental issues throughout her life.  For that additional $239/year premium she only has to pay 20% of fillings out of pocket.   To get that $239 back from the insurance she only needs $299 in basic &/or major.  

The bottom line is that this company has decent dental coverage aside from the low maximums. It is clear the true premiums are subsidized by the employer.

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THE FINAL WORD

 

By definition, there is actually no true dental insurance.  "Insurance" replaces what has been lost.  The reality is that an employer has negotiated a contract with a dental insurance company.  The insurance company's responsibility is not to remedy your loss, only provide what is in the contract.   Dental insurance can be a nice benefit as long as you know what you are getting.  Only 50% of our patients have dental coverage.

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For dental insurance to pay its contracted amount towards a procedure, you must meet all of the following criteria:

1. The procedure is covered by your dental plan.

2. The insurance company approves the procedure. It's not always enough that the dentist says it is needed.

3. You have not reached your yearly maximum.

Even if there is only 1 option to fix a dental problem and that option is not a covered benefit, your insurance pays nothing.

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DEFINITIONS

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"Basic": 1 of the 3 categories that all dental procedures fall under.  "Basic" includes most fillings and typically root canals, oral and periodontal surgery.

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Dental Maintenance Organization (DMO):  Type of managed care plan whereby a contracted dentist is paid a fixed monthly fee per patient on that plan, whether the patient goes to the office or not. The listed dentist(s) must provide all covered services to patients on that plan for typically no additional fee from the insurance company or patient.  The participating DMO dentist can charge the patient their normal fee if the treatment is not covered.

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Direct Reimbursement:  A very simple and straight-forward dental insurance coverage concept. The plan is managed by the employer, not an insurance company. You have the freedom to choose any dentist for treatment. The plan reimburses the actual amount spent at the dental office, not based on the treatment. This style of dental insurance meets the fairness criteria recommended by the American Dental Association and myself. The ADA has setup an elaborate web site with more information on direct reimbursement at www.ada.org/dr.

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Fee Schedule:  Where an insurance company has a specific fee they will pay for each procedure covered by a dental plan.  These fee should be found in a benefits booklet.  You may usually choose any dentist, but insurance will only reimburse that specific fee set by the insurance company and any difference the patient must cover.  Typically fee schedules are 15-35% of any "usual fee" and it is expected that a substantial portion of all treatment will paid directly by the patient.

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Managed Care/Health Maintenance Organization (HMO):  Plans that control costs by restricting what office treatment may be administered, the frequency of treatment, and how much is paid towards the treatment.  A list of dentists contracted with this plan is who you must seek care from.  Premiums to the HMO are usually paid for by an employer at a fixed price per patient. Patients generally do not have any significant "out-of-pocket" expenses. You will not know the amount an HMO dentist is reimbursed by an HMO.  You cannot choose an office such as mine and utilize an HMO plan.  Less than 30% of all dentists in the United States participate in HMO plans.

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"Major": 1 of the 3 categories that all dental procedures fall under.  "Major" includes crowns, bridges, dentures, and sometimes oral and periodontal surgery.

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Preferred Provider Plan (PPO): Type of managed care plan that contracts with a group of dentists to provide treatment for discounted fees to people enrolled in the plan.  Covered patients usually must select a dentist from the PPO list, and they may or may not be able to switch dentists.  This sometimes is identical to Managed Care.

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"Preventive": 1 of the 3 categories that all dental procedures fall under.  "Preventive" includes standard cleanings, x-rays, and exams.

Usual, Customary, Reasonable: Usual Fee is what an office charges for a procedure.  The Customary Fee is the amount the insurance company deems acceptable for a procedure.  My fees are nearly always within the usual and customary fee of insurance companies.