What You Don’t Know About Dental Insurance

What you don’t know about dental insurance isn’t going to kill you, but it may take an unexpected bite out of your bank account. Thus, if you’re part of the estimated one-third of Americans without dental insurance coverage, you should learn everything about the topic before opting into a dental insurance plan. Likewise, if you are already on a dental plan, it may be worthwhile to conduct a cost-benefit analysis of the plan and your usage of it. Even if your dental plan is an employment perk, fully paid for by your employer, you should familiarize yourself with the plan and what it provides, as coverage may be limited.

Premiums Versus Coverage Limits

Perhaps the first dental insurance detail to consider is premiums. On average Americans pay about $360 per year—or between $15-$50 per month—for dental insurance, with rates based on state regulations and on extent of coverage. Family plans are generally less expensive, as most insurers provide discounts to account for the increased premium numbers. These premiums provide each family member with a maximum benefit coverage limit generally ranging from $1,000 to $2,000, with all additional expenses paid by the patient.

Less than 5 percent of those covered by dental insurance max out their benefits in any given year, suggesting that coverage is reasonable. However, due to the type of coverage, many insured patients still end up paying additional out-of-pocket expenses.

Most Coverage is Tiered –100/80/50 — According to Procedure

The vast majority of dental insurance plans provide what is known as 100/80/50 coverage, with each of the numbers representing the percentage amount the insurer will pay for particular dental procedures, with the remaining percentages considered out-of-pocket. As these plans focus on preventive care, they provide 100 percent coverage for the basics like annual check-ups, teeth cleaning, and X-rays. Most “simple” procedures, such as fillings, extractions and periodontal work receive 80 percent coverage (though some plans use a smaller 75 or 70 percentage figure). All major procedures, such as root canals, crowns, bridges, implants and dentures, receive 50 percent coverage (with some plans offering even less).

Different Types of Dental Insurance Models to Consider

Generally speaking, dental insurance is offered under either Dental Health Maintenance Organization (DHMO), Preferred Provider Network (PPO) or indemnity model. The basic difference between the models includes:

• Indemnity—Allows the insured to pick their own dentist and pays a percentage of the dental provider’s fees. As the most flexible model, it usually charges the highest premiums, but also comes with co-payments, deductibles, and/or the 100/80/50 tiered coverage.
• DHMO—Requires the patient to see a DHMO-member dentist, and generally provides good coverage for the basics. Usually offered with the lowest premiums; however, some major procedures may not be covered at all under the 100/80/50 umbrella.
• PPO—Similar to a DHMO, but allows coverage if the insured visits a non-network dentist. However, offers lower out-of-pocket fees when the insured visits a network-member dentist.

The bottom line is that dental insurance is offered under a wide variety of options that may not prove worthwhile to the dental patient. Island Tower Dentistry recommends that you carefully weigh the cost of the premiums against what the various plans offer to cover for each procedure. There may be exclusions to your plan which may not have been considered. Ask if your insurance covers pre-existing issues, bridges, Implants and other dental treatments. While the policy terms may appear favorable upon first glance, a careful examination of its potential limitations warrants consideration.

Among those limitations are those mandating your choice of dentist. And, for the record, Island Tower Dentistry will assist you to submit to your PPO. But we do have an excellent track record of maintaining the oral health and bright smiles of our Marco Island patients, and in doing so at a reasonable cost.  If you would like to see what the team can do for your oral health and smile, contact us today at 239-394-1004 to make an appointment!