Dental Benefits (Insurance) - Choices/Types

Confused about your choices of dental benefits plans and the implications for your oral health care? You are not alone.  With the many options available, it’s easy to get lost in the maze of insurance terminology.

Dentistry is different from medicine and dental benefits are different from medical insurance.  Dental insurance is really a misnomer.  Dental benefit or fee assistance are more appropriate terms.

Dental care is a predictable expense and not catastrophic in nature.  Preventive care, including regular checkups and cleanings, is critical to maintaining oral health.  A good dental benefit plan is designed to ensure that you receive regular preventive care thereby avoiding more costly restorative treatment later.

Dental care is much lower in cost than medical care.  The main reason for dentistry’s success in cost control is its emphasis on preventive measures and early diagnosis.

Some employers offer more than one dental plan to their employees and it is important to understand your options.  Choosing the right plan for you and your family depends on your needs, the dentist you want to use and how much you can budget for your dental benefit plan.

Your options depend on the type of plans purchased by the employer.  Plans may cover as little as 30 percent or as much as 100 percent of dental services, but most fall in the 50 to 80 percent range.  Some plans exclude certain procedures while others provide benefits for all dental services.

There are four basic types of plans:

1. DIRECT REIMBURSEMENT PROGRAMS
   Direct reimbursement is a self funded plan in which employers provide dental benefits to employees.  This plan eliminates most of the administrative fees so more dollars to treatment.  These programs reimburse patients a percentage of the dollar amount spent on dental care.  There are total dollar limits, but these programs do not usually exclude coverage based on the type of treatment.  You and your doctor determine the appropriate treatment plan, not an insurance carrier.  These plans allow patients to go the dentist of their choice and place the patient in the position of being a wise dental consumer.
   
   
2. INDEMNITY PLAN
   These traditional programs pay a set percentage of the dentist’s fee or the plan administrator’s “reasonable” or “customary” fee limit, whichever is less.  Most indemnity plans use this type of payment schedule.  This plan allows patients to go to the dentist of their choice.  Although the limits are called “customary,” they may or may not accurately reflect the fees charged by area dentists.  However, exceeding the plan’s customary fee does not mean your dentist overcharged for the procedure.  Wide fluctuation and lack of uniformity by insurance companies in determining how plans establish “customary” fee levels have made this payment system controversial.  These plans categorize dental procedures with each category providing benefits at a different percentage.  Deductibles and excluded procedures are common.
   
   
3. PREFERRED PROVIDER ORGANIZATION   (PPO)
   In a PPO, dentists contract with certain organizations and agree to discount their fees to ensure a larger volume of patients.  Patients must choose from a list of providers.  If the patient chooses a dentist from outside the plan, benefits are reduced and may be eliminated.
   
   
4. DENTAL MAINTENANCE ORGANIZATIONS (DMO)
   Dental DMO plans require the patient to select a specific dentist who has contracted with the sponsoring insurance company.  Dentists agree to provide specific types of treatment to the patients at no charge.  For some treatments there may be a patient co-payment.  Patients may have to settle for less than optimal treatment options or postpone necessary services when co-payments do not cover all possible options.  Scheduling timely appointments could be a problem in this plan and dentists may not be conveniently located to the patient.

No matter which plan a patient has, the choice is always available for the patient to choose to have optimal treatment and making a financial arrangement with the dental office directly.

• Before you decide on any plan, ask the plan sponsor about the following:
• freedom of choice - can you continue to use your family dentist?
• exclusions - dental services not covered under a dental benefit program;
• limitations - restrictive conditions stated in a dental benefits contract, such as age, length of time covered and waiting periods which affect an individual’s or a group’s coverage. The contract may also exclude certain benefits or services or it may limit the extent of conditions under which certain services are provided;
• patient co-insurance - patient’s share of the dentist’s fee after the benefits plan has paid;
• annual or lifetime benefit maximums - the maximum dollar amount a program will pay toward the cost of dental care incurred by an individual or family in a specified period.

WHAT ABOUT PEOPLE WHO DON’T HAVE GROUP DENTAL PLANS?
Individual dental policies are not generally available.  Without a group dental plan, patients can choose a dentist and discuss appropriate financial arrangements with their staff.  If your employer does not offer a dental plan, you may wish to pass this information on to them.

Please remember that we are here to serve you and if you have any questions, please feel free to ask.

Facts Regarding Dental Insurance

Dental insurance is rapidly playing a larger role in helping people obtain dental treatment.  Since we strongly feel our patients deserve the best possible dental care we can provide and in an effort to maintain this high quality of care, we would like to share some facts with you about dental insurance.

FACT #1: Dental insurance is not meant to be a PAY-ALL.  It is merely an aid or fee assistance.

 FACT #2: Each subscriber (or patient) is responsible to know the coverage of his/her own dental insurance plan.  There are just about as many plans as there are employers, so plans vary widely and employers generally supply each employee with a packet containing the coverage information.  Before any dental work is contracted to begin, it is wise to know your own coverage limitations.  By making a phone call to your carrier, or by looking up the information in your insurance packet, you can obtain the information needed prior to contracting for any dental services.

FACT #3: Many plans tell their insured (subscriber) that they will be covered “up to 80% or up to 100%” for many preventive and diagnostic procedures.  We have found that most plans cover less than the average fee.  Some plans pay more, some less.  The amount your plan pays is determined by how much your employer paid for the plan.  The less the employer paid for the insurance, the less benefit or fee assistance you will receive.

FACT #4: It has been the experience of many dentists that some insurance companies tell their customers that “fees are above the usual and customary fees in your area” rather than saying to them that “the insurance company benefits are low”.  Remember, you will only get back in a benefit what your employer puts in, less the profits and administrative costs of the insurance company.

FACT #5: Many routine dental services are NOT COVERED by insurance plans and some plans will cover services once each year, but not two times, e.g. fluoride treatments. Some companies cover diagnostic models, others only cover models for orthodontic patients, etc., so knowing your own plan will help you in your decision processes and with your financial responsibilities.

Please feel free to ask us any questions you may have about these issues.  We want you to be comfortable in dealing with insurance matters and we urge you to consult us if you have any questions regarding our services and the fees charged for those services.  We will always help you with collecting your benefits for our services rendered.  If we take assignment on your insurance, that is considered a “loan” and we feel that 60 days is a reasonable length of time for us to wait for payment from your insurance company.  Please remember, the services we provide are for you and our agreement for payment for our services is with you, not with your insurance company.

Clarification on Dental Insurance Questions

A common question asked of our office is “Do you take (this or that) insurance?”  Our answer to that question is that we do not “take” any insurance.   We want to work for you, not the insurance industry.  We want your treatment to be based on your desires and needs, not driven by your insurance plan.

We do not accept insurance as a form of payment.  Our contract for services is with you, the patient, and not with an insurance company.  What we can do, as a service to you, is to provide assistance in helping you maximize the benefits you may receive through an insurance carrier.  We are happy to provide the necessary claim forms to send to your primary insurance carrier which lessens your personal paperwork. 

Patients with dental insurance coverage need to remember that professional services are rendered and charged to the patient and not to any outside party.  We provide our services for you without regard for the services that an insurance carrier might or might not cover.  This is because we care about you and your health.  We can only recommend treatment based upon the need of each individual patient.  Treatment is recommended and options are discussed with you so that you are in control of your own health.

We have many payment options available for our patients.  If you wish to discuss these options, we will be glad to do so once your treatment plan has been finalized.  Full payment for services rendered will be expected at the time of service unless you have made a prior financial arrangement with us.  We can also assist you in exploring the possibilities of outside financing for your dental needs.

Our office cannot accept responsibility for collecting insurance benefits or for negotiating a settlement on a disputed claim with a patient’s carrier.  However, again, we are happy to assist and actually do everything within our power to help you receive the maximum benefits allowable under your policy.  Many times, we call the carrier, write narratives to explain procedures that were performed, and “go to bat” in general for our patients.  The bottom line is that the patient is responsible for payment of his/her account within the limits of our financial policy.  Fee assistance from insurance carriers is determined by the insurance plan which is usually chosen by an employer.

We hope this clarifies some of the most frequently misunderstood ideas regarding dental insurance.  If you have any questions about our financial arrangements or other questions regarding insurance we are happy to assist you. 

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