Making Sense of Dental Insurance
Dental insurance can be complicated and confusing. We frequently get questions from parents trying to understand what is covered, what isn’t, and if insurance is worth the obligation. Finding a trusted family dentist is invaluable. We’re here to help you evaluate this important decision.
What are My Dental Plan Options?
Most dental insurance plans renew at the end of each calendar year. Unlike medical insurance that binds you to a minimum out-of-pocket cost, dental plans offer an annual maximum benefit, which is the limit to your insurance benefits. On average, this benefit is typically between $1000 - $3000 per year, and usually does not roll over to the following year (so with December 31st drawing near, we want to remind your family to take advantage of any remaining annual benefits before they expire).
In order to choose what’s best, it’s important to first understand how dental insurance works. While there are a variety of options (and of course the option to not carry dental insurance), we’ll begin by explaining the two main types of dental policies, which can be purchased privately or through an employer.
Dental Maintenance Organizations (DMO)
DMO plans are very similar to Health Maintenance Organization (HMO) plans for health insurance. These plans connect you with a network of providers for discounted rates, but guarantee benefits only if your child sees one of their contracted dentists. While these policies may be more affordable than a similar PPO plan, they greatly limit your freedoms in choosing a primary care dentist or needed specialist from their restricted network.
Preferred Provider Organizations (PPO)
Similar to DMOs, most PPOs have a network of contracted providers, however the patient has the power to choose which dentist they want to see. PPO plans grant your child the freedom to visit any pediatric dentist and often don’t require a referral when needing to see a specialist, whether that provider has an “in-network” or “out-of-network” relationship with your PPO plan.
What’s the Difference Between “In” and “Out” of Network?
Dental insurance plans provide a list of contracted providers they suggest their patients visit. A common myth regarding dental insurance is that you must always choose a provider from your policy’s list of network dentists. Although the insurance carriers sometimes use misleading language to support this myth, this is simply untrue. It’s important to understand that these common terms can have very different meanings when used in reference to dental insurance versus when used regarding the medical industry. In general, dental care does not have the same pricing dynamics as medical care, so you are unlikely to see the same level of price disparity between “in-network” and “out-of-network” in dental.
There are advantages and disadvantages in each option:
Choosing an In-Network Dentist
Advantages:
Out-of-pocket costs will likely be lower compared to out-of-network providers due to contracted rates with your insurance company.
Disadvantages:
There is no guarantee that you’ll have zero additional costs, as a copay or deductible may still be required at the time of your child’s service depending on their treatment. In addition, your annual maximum benefit still applies. As mentioned earlier, this “annual max” restricts the treatment costs insurance will pay to typically no more than $2,000, sometimes less, depending on the plan. Any balance remaining above your annual max will have to be paid out-of-pocket, regardless of the network status of your provider.
Treatment decisions can sometimes be restricted based on what your insurance will cover, regardless of if it’s the best option for your child’s health. For example, your insurance may limit preventative sealants and fluoride treatments once your child reaches a certain age, regardless of the dentist’s recommendation.
Your ability to choose a dentist for your child is limited to those offices that have agreed to the rates set by your insurance company.
Once you do find a great pediatric dentist in-network, they may not stay in-network. The list of preferred providers changes regularly as insurance companies negotiate for lower rates. Some providers will comply by lowering their service fees, while those that have the demand from other patients may choose to cease their participation in the carrier’s network.
Choosing an Out-of-Network Dentist
Advantages:
You can choose a pediatric dentist based on your family’s priorities, rather than those of your insurance company.
For some insurances, your carrier will fully match your in-network benefits with an out-of-network provider, and most will pay at least a portion of your child’s treatment benefit to an out-of-network provider.
Almost all out-of-network providers will work with your insurance and submit claims for treatment on your child’s behalf.
Disadvantages:
Out-of-network dentists don’t have contracted prices. Unlike in the medical field, it is uncommon for out-of-network pricing in the dental field to be excessive. However, it’s important to confirm your out-of-pocket costs before your child undertakes treatment so you know what to expect.
How Does Dental Insurance Work?
Regardless of the type of plan, you’ll want to consider an insurer that offers a variety of services without excessive clauses or restrictions. When reviewing or comparing policies, there are first some common terms to be aware of:
Annual Maximum Benefit: The total dollar amount a plan will pay for dental care in the term of your benefit period (typically a calendar year). Once this maximum is reached, all remaining dental services will be paid completely by you until your family's term renews.
Copayment (Copay) vs Coinsurance: A required payment due to your dentist at the time of services. This is usually a fixed amount (copay) or percentage (coinsurance) decided by your insurance carrier. This cost is typically paid at every dental visit, but the amount owed may vary based on your child's scheduled treatment.
Covered Services: A dental treatment for which payment is provided under your dental plan.
Deductible: This one-time fee is the amount owed for certain services that must be paid annually before your insurance benefits will be paid to your child's dentist.
Explanation of Benefits or EOB: A document provided by your insurance carrier detailing the treatment paid on your behalf to your pediatric dentist. This is not a bill, but rather a statement of the specific treatments and amounts your insurance company has decided to cover under the terms of your plan. Watch your EOB after each dental visit to be sure you’re taking advantage of your maximum allowed benefit before it’s too late! On average, only 5% of those enrolled in a PPO plan actually use their full benefit allowance.
Frequency Limitations: A restriction set by your insurance carrier for the maximum number of services paid in a certain period of time. For example, no more than two cleanings every 12 months or one panoramic x-ray every three years are common limitations.
In-Network Provider: A dentist who has agreed to participate in your insurance provider’s network, accepting the rates set by your insurance company in exchange for priority access to the pool of patients your insurance company serves.
Non-Covered Services or Exclusions: A dental treatment for which payment is *not* provided according to the terms of your dental policy. This typically includes cosmetic dentistry, or replacement of a lost retainer. Many parents believe these services are “not allowed” or restricted, however it simply means your insurance benefits will not apply. Rest assured, your insurance company cannot decide what treatment is “allowed.”
Out-of-Network Provider: A dentist who has not signed up to participate in your insurance provider’s network. If your family has a PPO plan, you can still choose an out-of-network provider. Your copay and premiums may be slightly higher, but nearly all out-of-network providers will work with your insurance and submit claims on your child’s behalf. It is always a good idea to review your out-of-pocket costs before allowing your child to undergo treatment, whether a provider is contracted or not.
Premiums: The monthly or annual cost paid by your family to enroll in a dental insurance plan.
Waiting Period: A period of time before your child is eligible for certain dental treatments. This is less common in employer-sponsored plans than with individual plans. Time periods may also vary based on the complexity and cost of necessary treatment.
What are the Benefits of Traditional Dental Insurance?
Once you understand the terms and conditions, take caution to choose a policy that will offer the most advantages for your family. While dental insurance isn’t a necessity for many, enrolling in a plan that fits your child’s needs can offer some great benefits.
Routine Exams
Bi-annual dental exams for children consist of much more than just a cleaning. A comprehensive preventative visit includes a thorough and professional removal of plaque and tartar on every surface of every tooth. Plaque and tartar are likely to accumulate in areas that are hard for kids to reach with a toothbrush alone. Your child’s hygienist can also advise them on tips for better brushing and flossing techniques. Then, your pediatric dentist will check for cavities and gum disease, an oral cancer screening, and a detailed evaluation of their dental x-rays to assess their teeth, gums, jaw, and all supporting structures. These preventative appointments are crucial to your child’s oral health and the development of their smile. Studies have shown that families with dental benefits are more likely to visit the dentist regularly for these routine exams and are less likely to need extensive dental treatment like extractions or root canals.
Lower Out-of-Pocket Costs (In-Network or Out-of-Network)
The greatest financial advantage of dental insurance is the feeling of savings. Due to the premiums being automatically deducted from your paycheck every two weeks, many families feel like they are saving money because they pay little to no out-of-pocket at each visit to the dentist. While the savings in actual dollars may be minimal, there’s a benefit in being able to pre-pay and budget the expenses for your family.
Many who have employer-provided insurance believe they must choose an in-network dentist to reap any benefits of their dental insurance. While this is true of DMO plans, for those with PPO plans, this isn’t true at all. Almost all dental practices will file claims for treatment under any PPO plan, regardless of if the provider is in or out of network with your insurance company.
Peace of Mind
When able to budget and pre-pay for health expenses, the likelihood of last-minute cancellations or putting off necessary treatment due to cost decreases. Many people appreciate this comfort and are thus more consistent in their routine cleanings. As an added benefit, children who have regular preventative visits are less prone to needing extensive (and expensive) dental treatment in the future.
What are the Alternatives to Traditional Dental Insurance?
If you find traditional dental insurance policies to not be the right fit for your family, there are alternatives.
In-House Wellness or Savings Plans
Most dentists recognize the benefits of dental insurance to patient retention and patient compliance with recommended preventative care. As a result, many practices have developed their own in-house plans designed to offer an alternative to a traditional dental policy. Though the terms will vary by office, many of these plans will accept an annual enrollment fee in exchange of discounted treatment costs, much like dental insurance, but without all the hidden fees and restrictions.
Paying Out-of-Pocket
Though the security of dental insurance can be comforting to some families, many have found a great sense of freedom and cost advantage to simply paying out-of-pocket. Being tied to an insurance plan can make you feel limited in the provider you prefer and treatment your child needs. Also remember, paying out-of-pocket for dental visits is much safer than it is when compared to seeking service in the medical field. It’s easy to confirm an estimate with your pediatric dentist before an appointment to avoid surprise bills later. If your family maintains regular exams and preventative treatments there will be little concern for a large procedure you won’t have time to budget for.
How Do I Know What Option is Best for My Family?
Regular dental treatment is a universal necessity for good oral and overall health. Although it can be tempting to find unconventional ways to save money, one thing you never want to skimp on is quality care.
First, find a practice that makes your family feel safe, comfortable, and professionally treated. Insurance or no insurance, parents who have found a pediatric dentist they trust are far more likely to go regularly. If your kids have been visiting the same dentist for a significant time or have recently found a dental team you love, ask what insurance companies they work with to see if your employer sponsors a PPO plan that you like. If not, ask your child’s dentist about their in-house wellness plans that may be more affordable than traditional insurance.
Dental Insurance: Your Next Steps
Don’t let the confusion about dental insurance keep your family from the healthy, long-lasting smiles you all deserve. Speak to your child’s favorite dental team today for help evaluating the pros and cons of traditional dental insurance.
