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How to Choose the Best Dental Insurance Plan for Your Family

Your family’s oral care is important to you. You want to make sure that preventative maintenance and routine dental work required will not set your budget back. That’s why you’ve been researching your options for dental insurance. But how can you choose the best dental insurance for your family? We hope the answer to our confused patient below helps you make the right decision.

Dear Tooth Truth,
It’s open enrollment time at work and I’m trying to find the best dental insurance for my family. I’ve tried to research it on my own, but there are so many confusing terms and I just can’t understand how these plans function. They don’t seem to work anything like my medical plan. Can you help me make sense of it all?
– Baffled by Benefits

Dear Baffled by Benefits,
Grab a cup of coffee and get comfy, because I’m going to break down some dental insurance basics to help you on your way.

Dental Insurance vs Medical Insurance

Dental Insurance has a long history. Thomas P. Connelly, D.D.S outlines some of the troubles with dental insurance in a recent blog. He offers great insight into the origination and development of dental insurance and why it differs so much from medical insurance.

Dental insurance caps have not changed since the 1960s, and patients and providers complain about pretty much the same things:

  • There is not enough coverage
  • Many things are not covered
  • Co-pays are too high
  • Limitations are too strict

DHMO vs PPO plan

There are two main types of dental insurance plans.

  • DHMO (Dental Health Maintenance Organization) — a network of dentists who agree to provide dental services at discounted rates
  • PPO (Preferred Provider Organization) — a network of dentists who partner with an insurance company to offer you discounted rates

Which plan is right for you? This is a meaty category, so let’s get visual with a chart to compare some of the big differences. If there are any bold terms I will define them in better detail below the chart.

 DHMOPPO
PROVIDER NETWORKLimited; must be assigned to aGeneral Provider(GP)Wider network of providers; typically have the option to stay In-Network or go Out-of-Network
SPECIALTY CAREMore Limited than GP network; must obtain referral paperwork from GP and sometimes wait for approval prior to seeing a specialist.Direct referral available (i.e. patient may go directly to a specialist without primary referral if needed)
EXCLUSIONS
/LIMITATIONS
Most plans will have a wide-variety of exclusions and limitations that may not be very clear to you or your provider.  Things like waiting periods, missing tooth clauses, cosmetic exclusion, and replacement clauses can affect the actual benefits you receive from your plan (even when a procedure is listed on your fee schedule). The other super fun thing for you and your Dentist is that all of this can vary greatly based on the employer group even within the same insurance.  For example, two patients with Humana may have plans that operate differently because the Humana plan is negotiated for cost and benefit spectrum by the employer.
PREMIUMSLowerHigher
PAYMENT PROCESS

With a DHMO plan there is a small monthly capitation paymentmade to your assigned GP.  They receive this payment every month while you/your family are assigned to their office.  This payment helps offset the lower cost and sometimes no cost procedures performed by the GP.  Every DHMO works differently but the DHMO fee schedule is typically a discounted set of fees agreed upon by the insurance/employer group/and PCD.  As a patient, you pay the full amount of the discounted fee directly to your GP.

The phrase COPAY can be misleading with DHMO plans because the DHMO insurance does not pay a portion of the procedure cost, the entire discounted fee is paid by the patient directly to the GP.

There may be additional allowances for things like lab fees and office visits that are charged when appropriate.  These fees are also your responsibility.  Many times, there is coverage for basic services but upgraded services may have an additional fee. For example, tooth colored or resin fillings may be considered an upgrade from a silver amalgam filling even though many dentists haven’t placed a silver filling in years.

With a PPO plan, a claim is filed, typically by the dentist on your behalf, to the insurance company.  The insurance will review the claim and either:

1.     Pay the claim

2.     Request additional information (an x-ray or narrative to describe the need for the procedure) or

3.     Deny the claim based on exclusion or limitation of your plan.

With an In-Network Dentist, there is an agreed-upon discounted fee schedule and your plan pays according to a percentage breakdown at a different percentage based on categories like Preventative, Basic, and Major.  Insurance should pay their part and you will pay your COPAY directly to your Dentist.

With an Out-of-Network Dentist, there is no discounted fee schedule.  The Dentist uses their UCR fees as a baseline for payment.  Insurance will pay according to a percentage but your COPAY will be higher.  This is the price of flexibility and sometimes it’s worth it to see the Dentist of your choice.

Common Insurance Terms Explained

  • Assigned to a General Provider: With the DHMO plans you must be assigned to a specific provider and you must be seen by that provider. You may change your assignment to a different provider with notification to your insurance company although the change sometimes doesn’t go into effect until the next month.
  • In-Network: With PPO plans, In-Network providers contract with the insurance company and agree to honor a reduced-cost fee schedule for their PPO patients.
  • Out-of-Network: With PPO plans, Out-of-Network providers will work with your insurance and may file claims, but they are not required to honor the lower cost In-Network fee schedule.
  • Capitation Payment: With the DHMO plans, the insurance pays a small monthly stipend or capitation payment for each family member enrolled and assigned to their assigned provider.
  • Preventative: This category of treatment usually includes things such as exams, routine cleanings, sealants and other procedures intended to “prevent” decay, gum disease, and treatment needs.
  • Basic: This service category typically includes things such as fillings, periodontal treatment and deep cleanings, extractions, root canals.
  • Major: Major treatment will include such things as crowns, and some tooth replacement options like bridges, and removable partial and full dentures. Sometimes sedation and implants are covered but it is very plan-specific.
  • UCR Fees: Usual Customary and Reasonable Fees are established by the provider and usually reflect fees that are customary for that provider’s region.

Dental Discount Plans

These plans do not work like traditional dental insurances. With a discount plan, you can go to any Dentist that accepts that discount plan and expect to pay an agreed-upon discount for services listed in the plan’s specific fee schedule.

At Lee Dental Centers, we work with so many insurances that we took the best of all the options out there and created our Dental Passport Discount Plan. Dental Passport strives to eliminate the confusing and costly elements of traditional insurance and cut out the limitations and exclusions so you can get the care you need. Because there are no exclusions for cosmetics and implants you can also get the premium care you deserve at a discounted price.

Learn more by watching our 2-minute Dental Passport Discount Plan video:

I hope you’ve gained a greater awareness of your plan options so you can make a more educated decision.

Want Affordable Dental Coverage?

At Lee Dental Centers, we want to give you the best chance at quality dental care. Sign up for our Dental Passport Plan and start saving today!

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