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Dental Insurance: What you need to know

With all eyes on healthcare, dental insurance can sometimes play second fiddle. But dental health affects your overall health, so having dental insurance can play a key role in your well-being.

Dental insurance membership has skyrocketed in recent years. Eme Augustini, executive director of the National Association of Dental Plans (NADP), said at the end of 2018, there were 260 million Americans with dental insurance benefits. That’s about 80% of the population (an increase from 57% in 2000, Augustini said.

"There has been a trend in growth of dental benefits over time... There's probably a couple of trends going on here that we can recognize. There's a relationship between employment and dental benefits enrollment. The great recession played a role in lower enrollment in those years and it took some time to recover. Since 2016, enrollment has been growing with a strong enrollment market," she said.

Augustini said 95% of Americans with employer-based benefits can get dental benefits. A strong employment market in recent years helped increase coverage.

Medicare Advantage and Medicaid often include dental coverage coverage. Those types of health coverage have seen membership growth over the past decade, which led to more people with dental protection. Between 2014 and 2017, Medicaid-associated dental benefit membership doubled and Medicare Advantage dental coverage membership tripled.

"Some of that rise can be attributed to the Affordable Care Act. When people went on the public exchange insurance marketplace, they realized that their children were eligible for Medicare or Medicaid… Another impact was felt with the expansion of Medicaid benefits under the ACA," said Augustini.

Despite the upward trends, there are still millions without dental insurance benefits. Not having coverage can have lasting overall health effects.

The NADP said that those "without dental benefits are more likely to have extractions and dentures and less likely to have restorative care or receive treatment for gum disease.”

NADP also said people without dental benefits are more likely to have other health issues:

• 67% more likely to have heart disease

• 50% more likely to have osteoporosis

• 29% more likely to have diabetes

And while nearly 100% of senior citizens reported having medical coverage in 2017, only 50% said they have dental insurance.

Let's take a closer look of dental insurance, what it covers, what it doesn’t cover and how to shop for coverage.

What is dental insurance?

Dental insurance is a set of products that pay a portion of costs associated with three categories of coverage:

●       Preventative dental care

●       Minor dental care

●       Major dental care

There are four types of dental insurance products: Dental HMO, Dental PPO, indemnity plans and discount plans.

What does dental insurance cover?

Dental plans include coverage for preventative care like routine exams, cleanings and x-rays. Some plans require a copay for preventative services, while others pay for all those services. It depends on the plan you choose, but preventative services are usually covered.

Many dental plans also include coverage for basic services, such as fillings and extractions, and major services like root canals and crowns.

Most plans have a level of coverage known as 100/80/50. That means:

●       Preventative care is covered at 100%. Basic procedures, such as regular checkups, cleanings, and x-rays, will follow under this 100% category with most insurance plans.

●       Procedures like fillings will be covered at 80%. Also included in this basic procedure category are extractions and periodontal treatment for gum disease.

●       Meanwhile, major procedures, such as bridges, crowns, dentures and with some carriers, are covered at 50%.

There are three types of dental benefits products, plus a discount dental plan option, which isn’t insurance. You also usually have the chance to purchase an orthodontic rider when needed.

The first type is a dental HMO. A dental HMO (DHMO) "refers to dental benefit plans that provide comprehensive dental benefits to a defined population of enrollees in exchange for a fixed monthly premium and pays for general dentistry services primarily under… arrangements with a contracted network of dentists," according to NADP.

Dental insurers usually cover only in-network providers in DHMOs. In-network dentists agree to accept a lower negotiated rate on services, meaning you pay less before your insurance carrier even gets involved. Non-network dentists can bill a patient for any remaining amount up to the billed charge.

When you stay in-network, you usually don’t have to submit claims yourself. The dental office will handle the paperwork, saving you the cost of your time.

Dental PPOs, which, according to the NADP, account for 87% of dental policies today, are plans that have contracts with specific providers "for the express purpose of obtaining a discount from overall fees," according to the NADP.

Unlike DHMOs, those with DPPOs have more leeway in terms of out-of-network coverage. Dentists who accept DPPOs get paid an agreed-upon rate and won’t balance bill patients for the difference between that rate and the dentist's standard rate.

For example, if a dentist charges $250 to fill a cavity to an average customer, but agrees to charge $200 in a DPPO, the dentist will lose that $50 difference. The patient won’t be held responsible for that amount.

Meanwhile, a dental indemnity plan is a fee-for-service plan. With this type of plan, a person can see any dentist; there are no contracts or discounted rates.

The other main differentiator between the indemnity plan, the DHMOs and DPPOs is that the insurance company will only pay a bill after the insured files a claim. In other words, you pay the bill and then submit a claim to be reimbursed.

The fourth option is called the discount dental plan. It’s not actually an insurance product. With these plans, dentists can agree to offer discounted rates, but there is no interaction between the plan and the dentist. The discounted rate is billed to the patient, who pays the dentist directly. 

What does dental insurance not cover?

Most dental insurance products cover the majority of basic procedures to some degree. However, you won’t get covered for every procedure. For instance, dental implants won’t likely get covered, though a few carriers will cover up to 50%.

Also not typically covered are dentures or orthodontic treatments, although with braces, a rider can be purchased to provide some coverage.

Cosmetic procedures, including tooth-whitening, are definitely high on the list of no-coverage. Another aspect of cosmetic procedures that is usually not covered is a tooth-colored filling. Most of the time, carriers will cover silver fillings, but if you want one to match your teeth, you’re responsible for the difference in cost.

Another major area not covered by dental insurance are procedures covered by medical insurance. Examples of this include Temporomandibular joint dysfunction (TMJ) and its related headache treatments, an accident involving your teeth and oral infections.

Dental insurance limitations

There are limits to dental coverage -- typically between $1,000 and $2,000. When you reach your dental benefit limit, your coverage stops and you pay out of pocket for the rest.

According to Delta Dental, the annual maximum would be specific to a time period, usually a calendar year.

"Beyond your annual maximum account, it is your responsibility to pay for any additional costs until your plan year starts over, "said Delta Dental.

Any riders that you have on your policy carry a separate cap; orthodontia is one example.

There’s also a deductible. The deductible is the amount you need to pay before your policy kicks in. For example,let’s say you have a $100 deductible. You get a crown that costs $700. You would pay the $100 deductible out of your own pocket and your carrier would pay the rest.

It’s important to note that preventative care isn’t often included in the maximum, allowing your dollar to stretch a little further.

Out-of-pocket, copays and deductibles vary, so read the fine print. One example is the difference between Delta Dental PPO Plus Premier and DeltaCare USA HMO. Both plans require copayments. However, only the DPPO has an annual maximum amount and a deductible.

How much does dental insurance cost?

Though costs vary based on your location and what services you want covered, the majority of insurance plans will not break the bank.

According to the NADP, employer-sponsored dental benefits run the employee between $15 and $20 per month for a DHMO. On the higher side, an indemnity plan cost between $35 and $38 per month. Discount dental plan fees cost under $15 per month for an individual but remember these are not insurance programs.

How do you file a dental insurance claim?

Most of the time, your dentist's office will reach out to your insurance carrier before the work is done to get an approval to move ahead. In this case, the legwork will be done by them.

Some dentists charge the patient who can then apply for reimbursement through the insurer, depending on their coverage. If this is the case, the patient will need documentation including x-rays, visit summaries and sometimes proof that a procedure was performed.

The second scenario is more prevalent when you use an out-of-network provider. You will also likely need an itemized bill list.

Choosing the right dental insurance plan

The first place to start looking for coverage would be a plan comparison site where you can plug in filters, such as your state and whether you want group or individual coverage and you will get a list of the best options for you.

You'll want to do your research before signing on the proverbial dotted line, though. Find out the in-network dentists near you before buying a dental plan. If you already have a dentist, make sure he or she is in-network. By choosing an in-network provider, you are making dental care more affordable for yourself.

Every state requires licenses for dental carriers that provide dental insurance. So, while there is not one type of accreditation, you can rest assured that someone is overseeing these carriers. One caveat: Discount dental plans aren’t licensed, though some states require a registration.

According to Augustini, comparison websites, such as the NADP site, list state-licensed carriers because there is no federal licensing board.

"Most of our member companies would be seen as a regulated entity at the state levels in the states they're offering insurance to," she said.

Another piece of your dental plan-choosing puzzle is figuring out what coverage you need. If you want low out-of-pocket cost, you would probably want to choose a DHMO. Maybe you work at a company known for its high level of cost-sharing with its employees? In that case, a DPPO might be your best bet.

Only you know the state of your mouth and what coverage you might need for the year. Don't cheap out if you know you need extensive work, because your whole body -- and wallet -- could pay the price.