Dental insurance is a type of coverage that helps pay for some of the cost of your care. It typically comes with a monthly premium and deductibles or copays at the time of service.
Most dental plans are either employer-sponsored or purchased through the health insurance marketplace or as a rider on medical insurance policies. All come with a variety of restrictions, including deductibles and frequency limitations.
When considering dental insurance options, it’s important to understand what it means when a provider is in-network or out-of-network. Most dental plans have a list of dentists that are in-network, and this is known as the Preferred Provider Organization (PPO) network. When a patient selects an in-network dentist, the fees are pre-negotiated and typically cheaper than what the insurer establishes as the Maximum Allowable Charge (MAC) or Usual and Customary Fee (UCF).
Out-of-network providers are those that do not have a contract with an insurance company and therefore cannot offer negotiated rates. Choosing an out-of-network dentist usually results in paying more for services at the time of treatment and having to submit a claim to the insurance company for reimbursement.
For a dental practice, being in-network with a insurance company offers many advantages. It helps patients find your office, makes it easy for them to schedule appointments and provides free marketing/advertising from the insurance company. However, being in-network does mean that you have to agree to a set rate of fees with the insurance company which can be frustrating for some practices.
Many dental insurance plans, such as PPO and EPO, allow you to visit any dentist you want, but in-network dentists have negotiated set rates with the insurer so that most of your costs will be covered – save for the normal deductible and coinsurance. These types of plans are also called full coverage or open access plans.
Credentialed dentists who contract with an insurance company go through a process known as credentialing. This typically includes a review of the dentist’s licenses, specialty certifications, malpractice insurance and other credentials. In-network dentists are bound by their contracts to follow the insurance companies’ “allowable charges,” which are set prices for each service based on a comparison of claims filed in various areas.
Out-of-network dentists are not bound by these fees and can decide their own rates for services. However, this freedom can sometimes mean higher fees for patients. Successful out-of-network dental practices still need to spend time managing patient billing and ensuring they collect the right amount from their patients, so outsourcing their insurance claim processing can be helpful for them too.
Most dental plans offer no-cost preventive care, which typically includes regular cleanings and checkups every six months, certain types of routine x-rays, and cavity-preventing sealants for children. Depending on the specific policy, other treatments may be partially or fully covered as well. Dental plans often have a plan deductible, a set dollar amount that the insured must pay out-of-pocket before the insurance begins to help. The deductible may also apply to copays, which are fees the patient pays at the time of treatment.
Many dental insurance plans are Preferred Provider Organization (PPO) or Dental Health Maintenance Organization (DHMO) options, and work similarly to health-insurance HMOs and PPOs. These plans generally have a network of dentists that the insurance company has negotiated reduced rates with, so patients are encouraged to stay in-network. Patients can also go to non-network dentists, but they will typically have to pay a higher portion of the cost. Many DHMOs have an annual maximum limit on how much they will cover, and some may even have lifetime limits as well. These limits are discussed in detail in the specific policies themselves.
Dental insurance plans generally cover basic restorative services like fillings and tooth extractions, as well as major restorative treatments such as crowns, bridges, dentures, and root canals. Other common coverage includes routine teeth cleanings and x-rays. However, cosmetic procedures are rarely covered by dental insurance, and orthodontia is often excluded from coverage altogether.
Most dental plans have a maximum amount they will pay in a plan year, and many also have a lifetime maximum. While these limits may seem restrictive, they are designed to keep overall costs down for both the plan purchaser and the insurer. Most dental insurance companies use the ADA-endorsed “usual, customary, or reasonable” (UCR) fee limit as a benchmark to determine what to pay for a particular service.
Some plans, called dental health maintenance organizations or DHMOs, resemble health insurance HMOs in that patients designate a primary care dentist who manages their access to specialists. DHMO plans have lower annual fees (called premiums) and do not typically have a deductible, but they will only cover treatment received from in-network providers.
While dental insurance can pay for two cleanings a year and help reduce costs when you need restorative care, it doesn’t cover every procedure or prevent all problems. It’s important to understand the limitations of your dental plan before you sign up.
Limitations include a deductible, annual maximum, and exclusions. A deductible is the amount you must pay out of pocket before your dental insurance will begin to pay for procedures. A policy’s annual maximum is the total dollar amount that the dental insurance will pay for procedures during a calendar year. Some plans also set a lifetime maximum for specific services like orthodontia.
Another limitation is a fee-for-service or managed fee-for-service dental plan’s Usual, Customary and Reasonable (UCR) Schedule. These are the fees that a dental insurance company believes to be reasonable and normal for a particular service in your area. It may differ significantly from the actual fee charged by your dentist. This can result in significant out-of-pocket costs for the patient.