Understand how your Dental Insurance works - compare options before you buy a dental plan

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   Dental Insurance can be very hard to understand, but that doesn’t necessarily mean that it is worthless. In order to get the most benefits from dental insurance, you will need to understand how it works. As always, Information is key. In this article, I will explain how to benefit from dental insurance and I will try to address such questions as: How does the dental insurance work? What is the best dental plan? What is the difference between dental PPO and HMO plan? What is a waiting period? How much does dental insurance Cost? Am I required by law to have dental insurance? Individual vs Group Dental- which one is better? What is covered by the dental insurance? What’s the difference between in-network and out-of-network care?

All of this information will  help you decide if the dental insurance is worth the cost. Here is a side by side comparison of various dental plans and the cost. If you have questions, please feel free to reach out to us, we are a licensed insurance agency in California and can help! 

	Delta Dental CoveredCa (only available with Medilcal Plan through Coveredca)	Blue Shield Enhanced Dental HMO	Blue Shield Dental PPO Plan	Renaissance Dental Indemnity (PPO) (plan pays at max after 3 years)	Delta Dental PPO (plan pays at max after 3 years)
	$54/month	$17.6/month	$35/month	$75/month +$35 sign up fee	$39.28/month + 35 one time sign up fee
Deductible	$50	No deductible	No deductible	$50	$50
Calendar year max	$1500	n/a	$1250	1st year-$1,000 2nd year-$2,000 3rd year-$3,000	$1000
Cleaning	$0	$0	$0	$0	40%
Filling	20%	$20	20%	20%, 40%, 50%	50%
Crown	50%	$350	50%	20%, 40%, 50%	0% (first year, then it covers up to 50%)
Molar Root canal	50%	$355	50%	20%, 40%, 50%	0% (first year, then it covers up to 50%)
Single tooth extraction	20%	$40	20%	20%, 40%, 50%	0% (first year, then it covers up to 50%)
Removal of impacted tooth- complete bony	20%	$225	20%	20%, 40%, 50%	0% (first year, then it covers up to 50%)
Adult Orthodontics	Not covered	$2650	n/a	10%, 25%, 50%	n/a
Child Orthodontics		$2350		10%, 25%, 50%	n/a
Local anesthesia	$0	$10	20%	$0	u/k
Implants	n/a	n/a	50%	n/a	n/a
Caries Risk Management	$0	$0	$0	$0	60%
Waiting period	6 months for major- (Waivered Condition provision, as defined in Health & Safety Code 1357.50 (a)(3)(J)(4)  and Insurance Code 10198.6(d)	n/a	Subject to 6 or 12 month waiting period	None (but benefits are limited in the 1st and 2nd year, 3rd year it pays at maximum)	Subject to 6 or 12 month waiting period

this is an estimate. For a complete summary of benefits, please read the brochure and disclosures. 

Here is what you should consider when shopping for a dental plan:

How does dental insurance work?

If you’ve had health insurance, you’re going to be familiar with how a dental plan works. If you are still confused, I’ll explain how it works.

• You pay a premium, a certain amount monthly, to buy the dental insurance plan.

Your insurance wont’ pay for everything, so there are a few things you may want to know like deductibles, coinsurance and copays.

• Your deductible is what you have to pay out-of-pocket for services covered by your plan before the insurance company pays.
• Your plan may include copays, a fixed cost you pay for a certain service, like an X-ray.
• Coinsurance refers to the percentage you pay of covered expenses after you meet your deductible. So if your coinsurance for a filling is 20%, and the cost for that service in-network in $100, you would pay $20 of that. The insurance company would pay for the rest of your covered expenses up to your annual maximum.

How much does dental insurance Cost?

The answer is – it depends.

The HMO plans tend to be less expensive and PPO plans a bit more pricy. Before buying dental insurance, first ask yourself what are your needs?  Do the math. Often your annual premium is less than the cost of two visits to your dentist per year for regular check-ups. You can call your dentist and ask for the price of a visit if you pay yourself, without insurance. It’s likely that dental insurance is cheaper than paying for two visits out of your pocket. Plus, you get the added benefits of having dental coverage that will save you money in case unexpected dental issues come up. See above, the sample comparison of various dental plans available in California. By the way, comparing the dental benefits side by side is a great way of determining what type of plan would benefit you the most! There are some discount plans for as low as $7/month. PPO plans range from $35 to $80/month. The comparison is for information only and is based on California zip code. 

Am I required by law to have dental insurance?

The answer is No. The Affordable Care Act (ACA), doesn’t legally require adults to have dental insurance. However, having dental coverage is an important part of staying healthy and having access to preventative dental services. It is up to you whether you decide to buy dental insurance or choose to pay the full cost of dental care out of your pocket.  

What is covered by the dental insurance?

HERE IS THE TYPICAL BREAKDOWN OF DENTAL BENEFIT CATEGORIES.

·         Major– is Usually covered at 50%- Which means the insured (patient) pays the other 50%- Most of the time crowns, bridges, dentures, partials, inlays, onlays, etc are considered major.

·         Basic– Usually covered at 80%- Which means the insured (patient) pays the other 20%- Most of the time fillings, extractions, periodontal services, root canals, core build up, quadrant scaling, scaling and root planing, etc are considered basic.

·         Preventative– Usually covered at 100%- Which means the insured (patient) pays nothing additional- Most of the time routine cleanings, x-rays, exams, dental sealants etc are considered preventative. There are usually timing limitations to the cleanings and sealants, these are different on almost every policy.

Waiting Period? Group Insurance Vs. Individual Insurance?

In addition, I would like to outline one very important aspect of dental insurance. Most individual and family dental plans have a waiting period for basic and major services. Group plans or employee benefits plans usually don’t have a waiting periods due to various reasons. Due to the risk of adverse selection, the insurance companies impose a certain dental plans. For example, some contracts will not let you get any basic services in the first 6 months of the policy and you might have to wait as much as 12 months in order to get your major procedures covered. There are some exceptions, and I will have one of those plans in my comparison chart that I will post under this video.

Now that you understand the basics of how dental coverage works let’s talk about the types of dental insurance plans, which is another area that can be totally confusing and can change each time you renew your health insurance if your dental insurance is part of that plan. It can change yearly, and this can determine how much out of pocket you pay.

So, let’s explore various types of dental insurance and try to determine what is the best plan for you?

There are three basic types of dental insurance plans: Dental HMOs, Dental PPOs and Dental Indemnity plans. To find the best one for you, you should consider what your most important deciding factors are (for example, cost, keeping your dentist, flexibility) and look at dental plans that suit your needs.

Key characteristics of the three basic types:

Dental HMOs:

HMO stands for Health Maintenance Organization. If you participate in a Dental HMO, you generally have

·     Lower premiums than either a Dental PPO or an Indemnity plan

·     No annual maximum to the benefits the plan will pay

·     A restricted network of dentists and dental providers

·     No benefits for going to out-of-network dentists or providers

·     A list of copays (standard costs) you will spend for office visits and specific dental services

Dental PPOs:

PPO stands for Preferred Provider Organization. If you choose a Dental PPO, you can expect

·     Higher premiums than a Dental HMO

·     An annual maximum to your benefits (often $1,000, but it varies by plan)

·     A network of dentists or providers that have agreed to offer discounted services and that you can choose to use to save money

·     Some benefits paid to out-of-network dentists or providers you might choose to go to instead

·     A list of the percent the insurance company will pay for different dental services. (For example, many Dental PPOs cover 100% of preventive services like exams and cleanings but may pay only 50% for major expenses like crowns or bridges.)

Dental Indemnity plans:

This is traditional fee-for-service insurance, offering the most freedom of choice. You can expect

·     Higher premiums than either a Dental HMO or Dental PPO

·     An annual maximum to your benefits

·     A small deductible you have to meet

·     No network of providers, meaning you get the same benefits with any dentist you choose (but also meaning there are no network-negotiated discounts on dental services)

·     A list of the percent the insurance company will pay for different dental services, just like with Dental PPOs

As I mentioned earlier, I will have a link to my blog with a side by side comparisons of these plans. You can compare various plans and also see the cost of dental insurance for each of the plans.

Now, let’s take a look at a very important aspect of dental insurance and find out-

What is the difference between in-network and out-of-network dental care?

In-network care means that you can only see the doctor or doctors that are in network or have a contract with your insurance company. Out of network means that you can go to other doctors, but you have to be extra careful and don’t assume that because you will end up paying more for out of network care.

Here are a few things to keep in mind

Cost and convenience. You can help make more affordable dental care for yourself by staying in-network. A dentist in-network has agreed to lower rates on services.

Also, some dental insurance plans don’t pay any benefits to out-of-network dentists at all, or pay less. Check your plan before you buy.

Finally, if you stay in-network, you often won’t have to deal with submitting claims yourself. The dental office and your insurance provide will handle that. If you are out-of-network, you may have to submit your own claims and wait to be reimbursed. Again, before you buy a dental plan, I will highly advise that you search whether or not your doctor is in network or find another doctor that woks with your insurance company.

NAVIGATING THE DENTAL INSURANCE “MAZE”

1.      Pay attention when you are buying the insurance. If you are at work and the employer is offering multiple plans, spend some time really researching which plan is best for your family. If you really only need dental then may be a basic dental plan will be sufficient. If you are planning a major procedure like root canals, crowns, etc. then you may want to get a more expensive plan that pays more for these procedure and is less likely to exclude services.

2.      Call your insurance company and ask questions. Remember you are paying them, ask them questions try to understand your plan.

3.      Read the booklet that your get from the insurance company. It is ultimately your responsibility to know how your plan works, so do your homework- read the summary of benefits for your plan. Believe me, this will save you tons of money!

4.      Work with an insurance agent. Agents will be able to compare various options and help you choose the one that is best for you. If you don’t have an agent, we will be glad to help you in California.

5.      Get a treatment plan from your Dentist. This is a great way of estimating what dental work needs to be done, when and how much it will cost you.

6.      Do the math! Call your dentist office and ask “How much did we spend total aside from insurance last year?” If this amount is less then your insurance premium maybe you should just pay out of pocket or utilize an HSA (health savings account). It really doesn’t make sense to pay more for insurance then you get in benefits year after year. Again, Do the math; it will help you make the right decision.

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