While the thought of sitting in a dentist’s chair makes some people anxious, the potential cost also puts many off. If you have dental insurance through your employer or can afford to buy it yourself, you’ll want to choose a plan that covers the dental care you and your family will need now and in the future. .
According to the American Dental Association, the cost of dentistry is a barrier to care for many consumers, more so than medical care, prescriptions, mental health care, or vision care.
But on the plus side, dental costs tend to be easier to anticipate (and smaller) than the wide range of medical bills any of us could encounter at any given time. Some dental care will remain an impromptu emergency, such as breaking a tooth. But less obvious dental needs can often be predicted (or avoided!) by regular routine cleanings and exams that include diagnostic X-rays to assess the overall condition of the teeth, gums, and jawbone.
Other needs to consider are if you or a family member may need more extensive dental care, such as braces or other orthodontics, dentures, dental implants, crowns or bridges. Although most dental insurance plans cover at least part of the cost of these more expensive treatments, the patient will also tend to pay a significant amount. On the other hand, many dental plans cover the lion’s share of the cost of more routine care, such as exams, cleanings, and fillings.
What is included in a dental plan?
Several types of services are included (to varying degrees) in typical dental plans:
- Routine and preventive care: These include periodic check-ups, cleanings, x-rays and fillings; fluoride and sealant applications to prevent cavities; and certain types of oral surgery, gum care (also called periodontics), and root canal treatments.
- Emergency care: This includes the repair or extraction and treatment of a cracked or broken tooth resulting from an accident involving the mouth and teeth.
- Complex care: This includes orthodontics, dentures or bridges. Many dental plans cover about half the cost of these types of procedures.
Types of dental plans: indemnity, managed care and discounts
Dental plans with freedom of choice, also known as dental insurance plans, offer the highest level of flexibility because they don’t have provider networks. The member is free to use any dentist and the plan will reimburse according to their fee schedule. But that doesn’t mean the plan will cover the full cost; the member is responsible for paying the difference between what the dentist charges and what the plan pays, and some dental insurance plans have very low coverage limits.
Since there is no provider network contract with a compensation plan, dentists are not required to deduct any portion of their bill – they can collect the full amount, including billing the consumer for the full cost remaining after the insurance plan has paid the amount it is willing to pay for that particular service. [This is in contrast with what most Americans are used to in terms of their health insurance: Since most health insurance plans are managed care plans with contracted in-network providers, most of us are accustomed to an EOB for medical care that shows the amount the provider billed, the amount that’s written off under the terms of the insurer’s network agreement, and then how the patient and/or the insurance company cover the portion that’s left.]
But many dental plans are managed care plans that require patients to choose from a pre-approved list of dentists in a network of providers who have agreed to lower their fees. These plans can be dental PPOs or dental HMOs, and the rules are quite similar to medical PPOs and HMOs, with the latter generally offering no coverage if the member is receiving treatment from a dentist who is not part of the network of plan providers.
Since dental HMOs tend to be more restrictive and do not cover out-of-network care, their premiums also tend to be lower than dental PPO premiums, if coverage amounts are similar. But you can get a dental HMO that costs more than a dental PPO, if the HMO offers higher coverage amounts and has a higher benefit limit. Dental insurance plans will tend to have the highest premiums for comparable coverage amounts because they give the member the most flexibility in which dentists they can use. But you’ll often find that the dental insurance plans available have lower coverage amounts, which makes up for the flexibility the plan gives you in terms of choosing a dentist.
There are also dental discount plans, which are not actually insurance. These plans offer a discount when you see dentists who have agreed to be part of the discount plan’s network, but the plan itself pays nothing for the cost of your care – you pay for your own treatment, but at the discounted rate . Dental discount plans tend to be cheaper than dental insurance, and they usually have no waiting periods before you can start receiving discounts (dental insurance plans often have waiting periods). waiting for benefits to take effect, especially for expensive dental work).
The Affordable Care and Dental Insurance Act
Starting in 2014, the Affordable Care Act began requiring all new individual and small group health plans to provide coverage for ten essential health benefits. One such benefit is pediatric dental care. But the rules for coverage of pediatric dental care are not the same as those for other essential health benefits. If you purchase health insurance in exchange for your state, it may or may not include pediatric dental coverage. As long as there is at least one stand-alone pediatric dental plan available for purchase, insurers are not required to incorporate pediatric dental coverage into the medical plans they sell, unless a state requires it. requires, and some do.
If you purchase a stand-alone pediatric dental plan, it will cap the total out-of-pocket expenses for pediatric dental care. For 2021, as was the case in 2020, disbursements under a stand-alone pediatric dental plan cannot exceed $350 for a child or $700 for a family plan that covers more than one child.
This limit on out-of-pocket costs for stand-alone pediatric dental plans contrasts with most adult dental plans, which cap the total. benefits in place. In other words, most adult dental plans limit the amount the plan will pay for your care (usually between $1,000 and $2,000 per year), while the ACA requires dental plans to pediatric dentistry limit the amount of member must pay a fee and there is no limit to the amount the insurance plan may have to pay.
If you purchase a medical plan that includes built-in pediatric dental coverage, the plan may be designed so that pediatric dental expenses count toward the plan’s overall deductible and out-of-pocket limit (which cannot exceed 8 $550 for a single person in 2021). The total amount of disbursements is always capped, but if a child needs only dental care during the year, the family’s out-of-pocket costs may be higher than they would have been with a stand-alone dental plan, since the overall health plan deductible will tend to be higher.
Dental coverage for adults was not addressed in the Affordable Care Act. There are a variety of adult dental plans available for sale, but they are not regulated by the ACA.
Dental plans and costs
If you get your dental insurance through your employer, you may only have one plan option available. But a larger employer may offer you a choice of plans, and if you purchase your own dental insurance, you can choose from any plan available in your area.
So how do you choose? The three most important factors are probably which dentists you can see, how much you will have to pay in monthly premiums, and how much expense you think you can comfortably manage.
As described above, some plans will let you see any dentist, while others will limit you to dentists in a particular network. But while a plan that lets you see any dentist sounds good at first, it might not be the best choice if it has lower reimbursement rates or a smaller benefit limit.
The affordability of a plan is based on its premium payments (often deducted directly from your salary, if your employer offers insurance) and the portion of dental costs that you must pay yourself, either because the plan does not not cover them or only cover part of the cost.
For example, a low premium dental plan may cost you less in terms of the amount you pay to purchase the coverage, but you may find that you end up paying a significant portion of the cost of complex dental treatments like bridges, implants or orthodontic appliances. – it may not be the market you were hoping for. Conversely, it may be overkill to pay high premiums for a high-end dental plan when your dental history is uncomplicated and you only need the dentist to clean your pearly whites twice a year.
Before choosing a dental plan, visit your dentist and have an exam that includes a series of diagnostic X-rays. Ask your dentist to assess your overall dental health and determine what, if any, complex procedures you may need in the near future. This needs assessment should direct you to the level of insurance that would best protect you and your wallet. While this won’t make it easier to choose a plan, it will simplify your options and your needs in determining the optimal match.
But it’s important to understand that if you buy your own dental insurance, rather than getting coverage from your employer, you’ll likely have a six-month or one-year waiting period before you get coverage for services that go beyond basic cleanings, x-rays and fillings. So you won’t be able to buy self-purchased dental insurance that will cover the crown you hope to get next month.
If you need dental care and don’t have insurance that will cover it, or if your dental insurance has a benefit cap that’s too low to cover the important procedures you need, there are places you can obtain free or low-cost care. -cost dental services in many communities.