Your Dental "Insurance"
Dental "insurance" is in quotation marks because, in reality, it is not insurance at all. It is a benefit that one's employer provides to offset the cost of regular and routine dental care. Insurance is a way to protect one from an unexpected financial loss due to illness or accident such as slipping and breaking a leg or being diagnosed with a disease, or theft, fire, or flood. These examples can often result in great expense to the victim, sometimes causing catastrophic financial problems, and insurance acts as a safety net. Most dental "emergencies" are not unforeseeable results of an accident, but rather of neglect, and even in the case of a true dental emergency, the cost is rarely even close to that of its medical counterpart.
Dental benefits policies provide a set dollar amount per year that is available to the covered individual for a variety of dental services. The levels and percentages of coverage are determined by your employer and are based on the amount they wish to pay in premiums. Preventive care (exams, cavity detecting x-rays, and dental cleaning) is most often covered at or near 100% while the individual is required to participate financially in a portion of the cost of other dental services, such as fillings, crowns, extractions, etc.
For this reason, Dr. Block stresses that the best dental insurance is regular preventive dental care! The smartest way to avoid extensive and expensive restorative dental treatment is to get regular dental check-ups and take care of problems when they are small.
These days, conversations about benefits can sound like alphabet soup. Below is a short description of each type of plan:
HMO: Health Maintenance Organization
Sometimes, in dentistry, you will hear it called a DMO or a DHMO. This type of plan only pays benefits if you receive services from a doctor who is contracted to provide care with this company. If you choose to see a doctor who is not a contracted "provider," your insurance company will not pay any part of the cost (with a couple of exceptions for emergencies). The doctors who participate in HMOs have agreed to accept the fees that the HMO has negotiated with them in exchange for the referral of a population of patients.
Patients often find that their scope of covered benefits is limited to the least expensive alternatives such as silver amalgam fillings instead of tooth-colored composite fillings or a base metal crown instead of a tooth-colored porcelain crown.
Most often, the premiums for a dental HMO will be lower and thus, more attractive to dental "insurance" consumers. But, buyer beware. Be sure to read all the limitations with an HMO plan before committing to it. Remember the saying, "You get what you pay for."
PPO: Preferred Provider Organization
A PPO gives the patient a choice between seeing an in-network, contracted doctor, or any out-of-network doctor he or she chooses. Reimbursement levels to contracted doctors are often higher than those of HMOs, but it is still the insurance company who sets the fee regardless of what it costs the doctor to provide the care. The PPO will pay benefits for services provided by an out-of-network doctor, usually in the same amount they would pay an in-network doctor. The patient is then responsible for paying the difference between the insurance benefit and the doctor's fee. Since the out-of-network doctor has not contracted with the insurance company, his or her fees will generally be higher than the in-network doctor's fees. How much of a difference depends on the policy itself and the particular procedure being performed. This by no means indicates that the out-of-network doctor is overcharging. Fees will vary from office to office and are based on the level of personal service, the quality of the materials and dental laboratories being used, the level of technology the office is equipped with, and the level of expertise of the doctor in a particular procedure.
This type of plan pays a percentage of the doctor's fee. Most plans pay 100% of preventive services, 80% of basic services (fillings, gum therapy, extractions, root canals, etc.), and 50% of major services (crowns, bridges, and dentures).
There is an upper limit on the amount at which they will reimburse. This is called "UCR (usual, customary, and reasonable). To see a detailed description of "UCR," check out the UCR page.