What Kind of Dental Coverage Do You Need?

From the WebMD Archives

If you want to get dental insurance, you'll find a lot of plans to choose from. The options may seem overwhelming, but there are some easy ways to find the coverage you need.

Employer's Plan or the Insurance Marketplace?

Most Americans with dental insurance get their coverage from an employer, rather than buying insurance individually, according to Evelyn Ireland, executive director of the National Association of Dental Plans.

There are also options available in the insurance Marketplaces set up by the Affordable Care Act. Marketplaces are web sites in each state that let you shop for insurance plans. In the Marketplaces, you may be able to get dental coverage as part of a health plan. You may also be able to get dental coverage as a separate, stand-alone plan.

But keep in mind, the health reform law treats adults and children differently when it comes to dental coverage. Dental coverage for children is considered an essential health benefit. That means insurance plans in the Marketplace must offer it for kids. But health insurance plans don't have to offer dental care for adults.

What Types of Plans Are There?

HMO. The least expensive kind of dental coverage is through a type of plan called an HMO. In a dental HMO, you get all your dental care from dentists in your plan's network. If you go out of network, you will have to pay the full cost of the care you get.

PPO. Most employer-provided dental insurance comes through a plan known as a dental PPO. These plans usually have slightly higher monthly fees -- called premiums -- than an HMO.

Like an HMO, a PPO also has a preferred network of providers. But the network is usually bigger than the network in an HMO.

In a PPO, you still get some coverage if you go out-of-network. You will have to pay more of the total cost than if you used a dentist within the PPO's network. But unlike an HMO, you won't have to pay the whole cost.

Dental discount plan. This option is more like a Costco or Sam's Club of dentistry than traditional insurance. You pay a monthly fee -- usually around $10 to $15, Ireland says. In return, you get discounts on dental care.

Dental indemnity plans. These have higher premiums and co-pays than either HMOs or PPOs. A co-pay is a set fee that you pay each time you see a dentist.

The advantage of dental indemnity plans is that they allow you to choose any dentist you want.

Continued

What Services Do Dental Plans Pay For?

Most dental plans divide their coverage into four general classes of service. Each covers different types of care:

Class I. Diagnostic and preventive care, like cleanings, checkups, and X-rays.

Class II. Basic restorative care, such as procedures like fillings and root canals.

Class III. Major restorative care, such as crowns and bridges.

Class IV. Orthodontia (braces). Not all plans have this coverage. The ones that do usually have a separate lifetime maximum, and may only cover braces up until a certain age, such as under 19.

"Dental coverage hasn't been designed to be really catastrophic coverage," Ireland says. "Instead, it has been designed more to encourage prevention and eliminate barriers to preventive care."

With a dental PPO, for example, coverage is typically "100/80/50." The plan pays 100% of preventive services, 80% of basic restorative care like fillings, and 50% of major restorative care. There is usually a $50 deductible. But Ireland says the deductible is often waived for preventive care and only kicks in when you need restorative services.

Dental HMOs, on the other hand, usually have specific copayments for services rather than a percentage. "HMOs generally say that when you go in for your dental exam, you pay $10. For a filling, you pay $20," Ireland says. "They don't state it as a percentage of some unknown number."

Dental HMOs also usually have no annual limit on coverage. There may be a coverage limit with a PPO.

Questions to Ask

Before you shop for dental coverage, ask yourself what's most important:

  1. Am I the type of person who doesn't like surprise expenses? If so, you might prefer a dental HMO, because it has more predictable costs.
  2. Do I want more choice in dentists? If you can accept slightly higher (and less predictable) costs in order to have a bigger pool of dentists to choose from, a dental PPO might be for you.
  3. Do I need unlimited freedom to choose a dentist? If, for example, you love your dentist and he's not in any HMO or PPO network available, the higher premiums and co-pays of a dental indemnity plan may be worth it.

Continued

If your company doesn't offer group dental insurance and there are at least 10 employees who want coverage, it's worth asking your employer to consider a group plan.

"Even if the employer doesn't pay any percentage and the employee pays for the whole premium, a group plan generally has broader coverage and lower prices," Ireland says.

WebMD Feature Reviewed by Lisa Zamosky on December 17, 2013

Sources

SOURCES:

News release, National Association of Dental Plans.

Healthcare.gov: "Can I Get Dental Coverage in the Marketplace?"

Evelyn Ireland, Executive Director, National Association of Dental Plans.

FAIR Health: "Dental Plans: What You Need to Know."

© 2013 WebMD, LLC. All rights reserved.

Pagination