Most medical plans do not include coverage for dental services. Often, routine dental services are covered through a separate plan. Like medical plans, dental Plans can be either Indemnity or managed-care plans. Indemnity plans offer greater choice of dentist but usually have higher premiums and out-pocket expenses. Most dental plans have certain defined out-of-pocket costs for members, like co-insurance, co-payments, and deductibles. These cost- sharing elements help control costs and keep plan premiums at affordable levels. However, dental plans differ in that they typically reimburse plan participants based on the “class of service.” For example, preventive and diagnostic services are often covered at 100% of the cost of the procedure, basic restorative services (such as fillings) may be covered at 80% and plan participants must pay more for major services such as crowns, which are covered at a lower rate, such as 50%.
Services offered under the dental plans include such services as regular checkups, cleanings, x-rays, and certain services required to promote general dental health. Some plans may also provide coverage for certain types of oral surgery, dental implants, or orthodontia.
In addition, there may be limitations on the number of times you can receive a procedure (for example some plans cover up to two cleanings a year) and your age (some services will be reimbursed for children, but not for adults, or vice versa). In addition, most dental plans have an annual maximum that they will pay for care in a plan year (which may be different than a “calendar year”). Once the annual maximum is reached, the plan will not cover any additional services until the start of the next plan year. If you only need routine care, such as exams, cleanings, and x-rays, you probably won’t reach your annual maximum. However, if you need complex dental services, you may reach your annual dollar limit.
Types of Dental Plans
Dental Health Maintenance Organization (DHMO)
In a DHMO, just like a medical HMO, you receive all your care from providers in your plan’s network. When you join a DHMO, you select a primary care dentist who coordinates your care, and who refers you to specialists if needed. When you need care, you must visit your primary care dentist first. There’s generally little or no paperwork for you if you belong to a DHMO. You simply pay your co-payment and your deductible (if you have one) when you visit your network dentist. DHMOs often do not have an annual dollar maximum on coverage. In general there are co-pay for services and insured might have to meet deductible.
Dental Preferred Provider Organizations (DPPO)
In a DPPO, just like a medical PPO, you have the choice of using providers inside or outside your plan’s network. You don’t need to choose a primary dentist, or get referrals to see specialists. But, if you do go out-of-network, your costs will usually be higher and might have to pay the full cost and then submit a claim to your insurer.
Dental Indemnity Plan
With a Dental Indemnity Plan, you can choose any dentist you want, and you don’t need a referral to visit a specialist. There is no network of providers in this type of plan. You will generally be responsible for a deductible and co-insurance for services. Most indemnity plans also have an annual benefit maximum.
Discount Dental Plan
A discount dental plan is not insurance. Instead, your plan contracts with a network of providers who have agreed to provide you with care at discounted rates.
