Let's Talk All Things Dental Insurance!

Understanding common dental insurance terms is crucial for navigating coverage options effectively. While many terms mirror those found in health insurance, dental insurance has its unique terminology. 

Let's explore some of the key terms first:

Premium: The amount paid for insurance coverage, typically on a monthly or yearly basis.

Deductible: The amount individuals must pay out-of-pocket before the insurance starts covering costs.

Coinsurance: The percentage of costs shared between the insured individual and the insurance company after the deductible has been met.

Copay: A fixed amount individuals pay for certain dental services, often for routine visits or prescriptions.

MOOP (Maximum Out-of-Pocket): The highest amount individuals have to pay for covered services in a given year, including deductibles, coinsurance, and copays.

Waiting Period: Time to wait before certain dental services are covered by the insurance plan. Waiting periods vary depending on the treatment, such as fillings, crowns, or orthodontic procedures.

Limitations: Restrictions on coverage for specific treatments or services, such as cosmetic procedures or orthodontics. It's essential to review these limitations to understand what services are covered and any exclusions.

Annual Maximum: The maximum amount the dental insurance plan will pay for covered dental expenses within a year. Once this limit is reached, the individual is responsible for all additional costs.

For more visit www.nadp.org or select Glossary of Dental Insurance and Dental Care Terms* 

Understanding these terms empowers patients to make informed decisions about their dental insurance coverage, anticipate out-of-pocket expenses, and maximize benefits. When selecting a dental insurance plan, it's essential to consider factors such as premiums, deductibles, coverage limitations, and annual maximums to ensure comprehensive oral healthcare coverage that fits individual needs and budgets. If you have any questions about dental insurance terms or coverage options, don't hesitate to reach out to the patient advocate program or your dental insurance plan. 

It is essential for both patients and dental practices to understand the different types of dental benefit plans.

Preferred Provider Organizations (PPO)

• PPO plans combine regular indemnity insurance with a network of dentists under contract to the insurance company.
• Contracted dentists agree to deliver specified services for set fees as per the contract.
• Non-contracted dentists may have fees either higher or lower than the plan allowance.
• Patients typically have the freedom to choose their own dentists.

(Pros of PPO Dental Insurance):

• Provider Network Flexibility: PPO plans offer a network of dentists to choose from, providing individuals with the flexibility to select their preferred provider. They can also seek care from out-of-network dentists, although at higher costs.
• No Requirement for Primary Dentist or Referrals: Similar to DPPO plans, PPO dental insurance does not typically require individuals to choose a primary dentist or obtain referrals to see specialists. This flexibility allows for easier access to dental care.
• Coverage for Preventative Care: PPO plans generally cover preventative services such as cleanings, exams, and X-rays, which can help maintain good oral health and prevent more significant dental issues.
• Potential for Lower Out-of-Pocket Costs: While individuals can go out of network with a PPO plan, staying within the network often results in lower out-of-pocket costs due to negotiated rates with participating dentists.

(Cons of PPO Dental Insurance):

• Higher Costs for Out-of-Network Care: Utilizing out-of-network providers with a PPO plan can result in higher costs, including higher deductibles, coinsurance, and fees for services not covered by the plan.
• Premiums May Be Higher: PPO dental insurance premiums can be higher compared to other types of dental plans due to the flexibility and choice in provider selection.
• Limited Coverage for Out-of-Network Providers: PPO plans may offer limited coverage or no coverage at all for services obtained from out-of-network providers, potentially leaving individuals responsible for a larger portion of the costs.
• Deductibles and Coinsurance: While PPO plans may offer lower out-of-pocket costs within the network, they often come with deductibles and coinsurance requirements that individuals must meet before the insurance starts covering costs.

Dental Health Maintenance Organizations (DHMO)/Capitation Plans

• Under DHMO or capitation plans, contracted dentists receive a pre-paid amount each month for each designated patient.
• Dentists must provide certain contracted services at reduced or no cost to patients.
• Patients usually must visit a contracted office to receive benefits, as individual service reimbursement is rare.

(Pros of HMO Dental Plans):

• Low or No Deductible: HMO plans often have low or even no deductibles, which means individuals can access dental care without having to meet a high upfront cost.
• Lower Premiums: Monthly premiums for HMO dental plans are typically lower compared to other types of dental insurance, making them more affordable for individuals and families.
• Coverage for Preventative Care: HMO plans usually cover preventative services such as regular cleanings, exams, and X-rays, promoting good oral health and helping prevent more significant dental issues.
• No Annual Maximum: Unlike some other plans, HMO dental plans often don't have an annual maximum limit on benefits, ensuring individuals can receive necessary treatments without reaching a coverage cap.
• Predictable Costs: With fixed copayments for covered services and no surprises from out-of-network charges, HMO plans offer predictable costs for dental care.

(Cons of HMO Dental Plans):

• Primary Dentist Requirement: HMO plans typically require individuals to select a primary dentist to assign themselves from within the plan's network. This limitation can be restrictive for those who prefer flexibility in choosing their dental provider.
• No Out-of-Network Coverage: HMO plans don't provide coverage for services obtained from dentists outside the plan's network. Individuals must stay within the network to receive benefits, which can be inconvenient if their preferred dentist isn't in-network.
• Smaller Provider Networks: HMO plans may have narrower provider networks compared to other types of plans, limiting choices when selecting a dentist. This can be problematic if individuals have specific preferences or if there are few dentists available in their area.
• Referral Requirement for Specialists: In HMO plans, individuals typically need a referral from their primary dentist to see a specialist. This requirement can lead to delays in accessing specialized care and may limit options for treatment.
• Less Flexibility: Due to the restrictions on choosing a primary dentist and limited out-of-network coverage, HMO plans offer less flexibility compared to other types of dental insurance plans.

Indemnity Plans

• Also known as traditional insurance, indemnity plans pay claims based on procedures performed, usually as a percentage of charges.
• Patients typically have the freedom to choose their own dentists.
• Most plans have a maximum allowance for each procedure referred to as "UCR" or "usual, customary and reasonable" fees.

(Pros of Dental Indemnity Plans):

• Freedom to Choose Any Dentist: One of the significant advantages of indemnity plans is the freedom to choose any dentist without being limited to a network. This flexibility allows individuals to maintain existing relationships with their preferred dentists or choose new ones based on personal preference or recommendations.
• Access to Dental Specialists: Under indemnity plans, individuals typically have the option to access dental specialists for specific treatments without needing referrals. This ensures access to specialized care when necessary, providing comprehensive coverage for a wide range of dental needs.
• Comprehensive Coverage: Indemnity plans often provide comprehensive coverage for a variety of dental services, including preventive care, basic procedures (such as fillings and extractions), and major dental work (such as crowns and bridges). This comprehensive coverage can provide individuals with peace of mind knowing that their dental needs are well-covered.

(Cons of Dental Indemnity Plans):

• Higher Cost: Indemnity plans tend to be more expensive compared to other types of dental insurance, such as HMO or PPO plans. The higher cost may be a deterrent for some individuals, especially those seeking more affordable coverage options.
• Maximum Allowance and UCR Fees: Insurers offering indemnity plans typically set a maximum allowance for each dental procedure based on "UCR" fees. If a dentist's fees exceed the insurer's UCR, individuals may be responsible for paying the difference out-of-pocket. This potential for additional expenses can be a disadvantage for some individuals.
• Annual Maximum Limits: Indemnity plans may impose annual maximum limits on benefits, meaning once this limit is reached, individuals must pay for additional dental costs out-of-pocket. This limitation can be problematic for individuals requiring extensive dental treatment or facing unexpected dental emergencies.
• Complex Claim Process: With indemnity plans, individuals typically pay for dental services upfront and then submit claims to the insurance company for reimbursement. This process can be complex and time-consuming, requiring individuals to navigate paperwork and potentially experience delays in receiving reimbursement for expenses.

Direct Reimbursement (DR®)

• Benefits in DR plans are based on dollars spent rather than treatment type.
• Patients can choose their own dentists and submit paid receipts for reimbursement.
• No insurance claim forms are required in some plans.

(Pros of DR Dental Plans):

• Flexibility in Provider Choice: DR plans allow individuals to choose any dentist they prefer, without being restricted to a network of providers. This flexibility enables individuals to select a dentist based on personal preference, convenience, or existing relationships.
• No Deductibles: Unlike some other dental plans, DR plans typically do not have deductibles. This means individuals do not need to pay a portion of the fees upfront before receiving reimbursement from their employer.
• Reimbursement for All Treatments: DR plans reimburse individuals for all or part of their dental costs, depending on the specific plan design. This can include reimbursement for preventive treatments as well as ongoing dental treatment throughout the year.

(Cons of DR Dental Plans):

• Lack of Regulation: DR plans are not typically regulated by state insurance departments, which may lead to variability in coverage and benefits. Individuals should carefully review plan details to ensure they understand the terms and conditions.
• Waiting Periods: Some DR plans may have waiting periods for benefits, during which individuals may not be eligible for certain treatments or services. This can delay access to care and treatment for dental issues.
• Higher Out-of-Pocket Expenses: Compared to other types of dental plans, individuals enrolled in DR plans may experience higher out-of-pocket expenses. This is because individuals typically pay the dentist in full for treatment and then wait for reimbursement from the plan, rather than paying a predetermined copayment or coinsurance at the time of service.
• Credentialing Process: Dentists participating in DR plans are not required to undergo the same rigorous credentialing process as those in PPO, EPO, and DHMO networks. This may raise concerns about the quality and qualifications of providers within the plan.

Dental Point of Service Plans (DPOS)

• Patients with managed care dental plans can opt for treatment from out-of-network providers.
• Reimbursement is often based on a lower table of allowances compared to in-network providers.

(Pros of DPOS Plans):

• Flexibility in Provider Choice: DPOS plans offer individuals the flexibility to choose their dental providers, similar to DPPO plans. This flexibility allows individuals to see any dentist, whether they are in-network or out-of-network, without needing a referral.
• In-Network Cost Savings: While DPOS plans provide out-of-network coverage, individuals typically enjoy lower out-of-pocket costs when they use in-network providers. This allows individuals to access affordable dental care while still having the option to see out-of-network dentists if needed.
• Coordination of Care: Like DHMO plans, DPOS plans may require individuals to select a primary dentist who coordinates their care. This can lead to more streamlined and coordinated dental treatment, ensuring continuity of care and appropriate referrals to specialists when needed.
• Coverage for Preventive Services: DPOS plans often cover preventive dental services, such as cleanings, exams, and X-rays, helping individuals maintain good oral health and prevent more significant dental issues.

(Cons of DPOS Plans):

• Higher Out-of-Network Costs: While DPOS plans offer out-of-network coverage, individuals may face higher out-of-pocket costs when they see out-of-network providers. This can include higher deductibles, coinsurance, and fees for services not covered by the plan.
• Primary Dentist Requirement: Similar to DHMO plans, DPOS plans may require individuals to select a primary dentist to coordinate their care. This can limit flexibility for individuals who prefer to see different dentists for different services or who want to change providers.
• Potential for Limited Provider Networks: Depending on the specific plan, DPOS networks may be smaller or have fewer participating providers compared to DPPO plans. This could limit individuals' options when selecting a dental provider, particularly in areas with fewer participating dentists.
• Possibility of Referral Requirements: While some DPOS plans may not require referrals for specialist visits, others may have this requirement. Individuals should review the specific plan details to understand any referral requirements and associated restrictions.

Dental Exclusive Provider Organizations (DEPO)

• EPO plans require subscribers to use only participating dentists for reimbursement.
• Access to care may be limited due to the closed panel groups.

(Pros of DEPO Plans):

• Minimal to No Out-of-Pocket Costs for In-Network Services: DEPO plans typically offer coverage exclusively for in-network services. When receiving care within the network, individuals often experience minimal to no out-of-pocket costs, even for services beyond preventive care.
• Affordability: The national average cost of DEPO coverage is relatively low, ranging from approximately $250 to $450 per year, making it an affordable option for individuals and families.
• No Referral Requirement: Referrals are not required as long as the chosen provider is in-network, offering individuals greater flexibility and ease of access to dental care.
• Coverage for Routine, Basic, and Major Dental Services: DEPO plans typically cover routine dental services, basic dental care (such as fillings and extractions), and major dental work (such as crowns and bridges), depending on the specific plan.

(Cons of DEPO Plans):

• Limited Coverage for Out-of-Network Services: DEPO plans do not provide coverage for out-of-network services. Individuals must stay within the network to receive benefits, which can be restrictive if their preferred provider is not in-network.
• Annual Maximum, Deductible, and Waiting Periods: DEPO plans often have an annual maximum limit on benefits, a deductible that individuals must meet before the insurance starts covering costs, and waiting periods for certain services. These factors may impact coverage and access to care.
• Network Limitations: Individuals may face limitations in provider choice and availability within the network, particularly if they live in areas with fewer participating dentists.

Table or Schedule of Allowances Plans

• Indemnity plans to pay a set dollar amount for each procedure regardless of actual charges.
• Patients are responsible for the difference between the carrier's payment and the charged fee.

Discount or Referral Plans

• These plans are not technically insurance but involve contracted dentists who discount their fees.
• Patients pay treatment costs at the contracted rate with no claim forms to file.

Visit www.nadp.org - consumer resources by clicking here*

Each type of dental plan comes with its own set of advantages and limitations. It's essential for patients to carefully evaluate their needs and preferences before selecting a plan, ensuring they receive the best possible dental care while managing costs effectively. Similarly, dental practices should be well-versed in the various plan structures to best serve their patients and navigate the complexities of dental insurance.

The Patient Advocate Program

In conclusion, navigating the world of dental insurance plans and finding the right dentist can be a daunting task. However, with the support of the Patient Advocate Program by Arevalo Elite Services, patients can access comprehensive guidance, personalized assistance, and unwavering advocacy every step of the way. Whether it's understanding the intricacies of insurance coverage, finding a trusted dentist, or advocating for fair treatment, our program is committed to empowering patients with the knowledge, resources, and support they need to make informed decisions about their oral health. With us by your side, you can navigate the challenges of dental care with confidence and peace of mind.

Contact us today! 

Office: (916) 269-9899 

Email: advocate@elitedentalservices.net

Website: elitedentalservices.net