Dental Care Plans
Categories of Dental Treatment
1. Diagnostic and Preventive
An important feature of a dental insurance plan, which is typically not found in a medical expense insurance plan, is the inclusion of diagnostic and preventive care. Most dental plans provide coverage for routine preventive procedures such as periodic teeth cleaning and fluoride treatments. An increasing number of dental plans require periodic examinations as a condition for continued coverage.
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2. Restorative
Restorative care means treatments, which restore functional use to natural teeth such as fillings or crowns.
3. Oral Surgery
Oral surgery means operative treatment of the mouth such as extractions of teeth and related surgical treatment.
4. Endodontics
Endodontics means treatment of the dental pulp within natural teeth, such as a root canal.
5. Periodontics
Periodontics means the treatment of the surrounding and supporting tissue of the teeth such as treatment for gum disease.
6. Prosthodontics
Prosthodontics means the replacement of missing teeth with artificial devices like bridgework or dentures.
7. Orthodontics
Orthodontics means treatment of natural teeth to prevent and/or correct dental anomalies with braces or appliances.
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Indemnity Plans
There are three different types of indemnity plans available, including
- Scheduled or basic plan;
- Comprehensive or nonscheduled plan; and
- Combination of both basic and comprehensive plans.
1. Choice of Providers
Some dental plans limit the insured’s choices of providers, but others simply limit the benefits to any qualified practitioner.
2. Scheduled vs. Nonscheduled Plans
Scheduled Plans
Basic or scheduled plans pay benefits from a list of procedures up to the amount shown in the schedule. Most plans provide first-dollar benefits without coinsurance or deductibles. Maximum benefits are often lower than the usual and customary charges of dentists who force the insured to bear a portion of the cost.
Nonscheduled Plans
With nonscheduled plans, benefits are paid on a reasonable and customary basis and are subject to deductibles and coinsurance. Services are usually divided into three broad benefit categories: diagnostic/preventive services, basic services, and major services.
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3. Benefit Categories
Dental insurance plans typically provide coverage for the following types of treatment.
Diagnostic and Preventive Services
Diagnostic/Preventive Services generally are not subject to coinsurance or deductibles.
Basic Services
Basic Services such as fillings, oral surgery, periodontics, and endodontics may require the insured to pay a deductible or 20% of the balance (the insurer would pay the other 80%).
Major Services
Major Services, such as inlays, crowns, dentures and orthodontics, could either have large deductibles or pay around 50% for services provided.
4. Deductibles and Coinsurance
Most dental plans have a deductible amount such as $25, $50, or $100, which must be met each calendar year. Generally the deductible does not apply to preventive care like cleaning and routine examinations.
5. Combination Plans
Combination plans combine features of both the basic and comprehensive plans. They generally cover diagnostic and preventive services on a usual and customary basis but still use a fee schedule for other dental services.
6. Exclusions
Dental plans typically exclude cosmetic services (unless required by an accident), replacement of lost dentures, duplicate dentures, oral hygiene instruction, occupational injuries covered by workers compensation, or services provided by government agencies.
7. Limitations
To help keep costs down, dental plans provide more limitations than deductibles and copayments. Most plans provide for calendar year maximum benefits and lifetime maximum benefits. Routine exams and cleaning are generally limited to once every 6 months, full mouth x-rays to once every 2 to 3 years, and replacement of dentures to once every 5 years.
8. Predetermination of Benefits
The predetermination of benefits (precertification or prior authorization) clause is found in most dental plans. This service, although generally not mandatory, will allow the insured and the dentist to know in advance what benefits will be paid.
Employer Group Dental Expense
Dental plans can be found in the form of individual plans or as group plans provided through the employer. Generally included in an employer group dental insurance plan is preventive care for up to two visits per year. However, it will not provide coverage for cosmetic treatment, and there may be limits on procedures such as braces or other appliances.
1. Integrated Deductibles vs. Stand-Alone Plans
Dental expense may be packaged or integrated with other health insurance benefits like major medical. In that case the integrated plan may have a common deductible. On the other hand, some integrated plans maintain separate deductibles for the medical and dental portions of the contract.
2. Minimizing Adverse Selection
Dental plans attempt to minimize adverse selection by utilizing probationary periods, where insureds that had no prior dental coverage are likely to have a large number of untreated dental problems. There can also be a limitation on benefits for late enrollees where benefits may be reduced for the first year. Even though dental coverage is regulated by COBRA continuation rules, it is seldom convertible like individual health insurance.
Pediatric Dental Coverage
Pediatric dental coverage is an essential health benefit under the Affordable Care Act that must be available as part of a health plan or as a stand-alone plan for children 18 or younger. However, insurers do not have to offer adult dental coverage.
Depending on the state, pediatric dental benefits may be offered through one of the following types of plans:
- A qualified health plan that includes dental coverage;
- A stand-alone dental plan purchased in conjunction with a qualified health plan; or
- A contracted/bundled plan.
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