Dentists love to tell their patients they "create smiles." But people who pay out of pocket or out of network don't often leave a dentist's office smiling. By better understanding dental insurance policies, a dentist near you can see you for procedures from routine cleanings to root canals within the framework of your dental coverage. More than 249 million Americans had dental coverage at the end of 2016, according to the National Association of Dental Plans. If you're wondering how to get the most out of your dental insurance, this consumer alert from the National Association of Insurance Commissioners (NAIC) will guide you through the ins and outs of coverages.
Types of Dental Insurance
There are four general types of dental coverage: 1) dental preferred provider organization (DPPO or PPO); 2) dental health maintenance organization (DHMO or HMO); 3) dental indemnity insurance; and 4) discount dental/dental savings plans.
PPOs are popular plans because they allow covered consumers to choose from an array of dentists and dental specialists. HMOs have specific dentists under contract with the dental insurance company and offer services at predetermined rates. The flexibility of PPOs trends toward higher costs for that type of coverage.
Through dental indemnity plans, insured consumers pay dentists directly for services rendered and later receive compensation from the insurance company through a sometimes lengthy claims-submission process. Dental savings plans are programs where some dentists agree to perform services for plan owners at a discounted price. Dentists are paid the discounted rate directly by the plan owner.
What Dental Plans Cover
Individual policies typically cover the following areas: preventative care (cleaning, routine office visits); restorative care (fillings and crowns); endodontics (root canals); and oral surgery (tooth removal, tissue biopsy and minor oral infection drainage).
Orthodontics (braces and retainers) are generally covered via a rider for both individual and group policies. Periodontics (scaling, root planning and acute infection and lesion management) and prosthodontics (dentures and bridges) are typically covered in later years.
Most plans cover 100 percent preventative care and apply copayments as a dollar amount (DHMOs) or percentage (DPPOs and dental indemnity). Preventative care generally includes oral evaluations, X-rays and sealants. Basic procedures refer to office visits, extractions, fillings, root canals and periodontal gum disease treatment.
Orthodontics often covered at a lower percentage amount or a lower dollar copay if you have a DHMO. Major procedures such as crowns, bridges and dentures are covered at the lowed percentage. Root canals are sometimes considered a major procedure and not a basic procedure. Some plans consider implants as major procedures now as well. Check your coverage to be sure.
Coverage Through Medicaid, Medicare & ACA
States are required to provide dentistry for children covered by Medicaid and the Children's Health Insurance Program (CHIP). But states individually decide whether to provide dental benefits for adults. You can determine what your state covers for adult dental care through Medicaid.
Traditional Medicare does not cover dental insurance or procedures, but the program does offer Medicare Advantage plans, which can offer some form of dental benefit.
Through the federal Affordable Health Care Act (ACA), you can obtain dental coverage in two ways on the Health Insurance Marketplace: 1) as part of a health plan; or 2) through a separate dental plan. You cannot buy a Marketplace dental plan without purchasing health insurance as well.
Under the ACA, dental coverage is deemed an essential health benefit for children. Health coverage for anyone 18 years old or younger must also come with dental coverage—whether a part of the health plan or as a separate plan.
You can learn more about dental coverage on the Health Insurance Marketplace website.
Supplemental Dental Insurance or Riders for Orthodontics
Orthodontia is often pricey. Orthodontics insurance (or a rider) offers a means of offsetting the costs not covered by your general dental coverage. Supplemental dental insurance for braces makes claims payments to the policyholder on a fixed schedule as procedures are completed.
Orthodontists do not participate in these plans, so there's no in-network cost control. You must have dental coverage in order to purchase an orthodontics rider or supplemental dental insurance.
How Much Do Procedures Cost?
There are varying costs for dental procedures, but you can get an idea for how much a procedure will cost you on FAIR Health Consumer's Dental Cost Estimator.
Our College Health Insurance Needs consumer alert is a valuable resource for college students and parents wanting to understand dental coverages, as well as other collegiate insurance matters.
Dental insurance is regulated by your state insurance department. If you have questions about your dental coverage, contact your state insurance department.