Tips for Choosing Dental Insurance

The following is a compilation of information from various sources that we find holds true in our experience at Orchid Dental Care. Please keep in mind that insurance policies vary greatly from carrier to carrier and year to year so this article reflects only our findings at this moment. However, we hope that gives you some insight from a healthcare provider’s point of view in determining if and which dental insurance plan fits your needs.

The bottom line to choosing an insurance plan is in assessing how much need do you have. It often helps if you have been to the dentist recently before making the choice. This way, you will actually have an up-to-date idea of what you need and how much it would cost for you and each member of your family if you don’t have insurance. From your treatment plan or needs assessment you can then move on to see which insurance plan has the benefits that cover those procedures to get the most of your money.
First decide on the Insurance Company. Where patients sign up to be covered by different insurances, dentists sign up to be providers for those insurances. In contracting to become their network providers, insurance companies negotiate the dentist’s fees for each of the plans they offer to patients.
Look for:
1. Quality of care: In general the negotiated fees are a fraction of the dentist’s usual fees. Therefore the different pay structure for dentists that belong to PPO and an HMO dental care plans may result in different quality of care, including quality of treatment and amount of waiting. For example, a dentist participating with a managed care program may end up having to see several patients to produce the same amount of money he would with a single PPO or cash-only patient.
2. Scheduling: some dentists (often those who work with HMO plans) offer a limited scheduling – both in days and times – for individuals covered under the plan. Make sure these can fit into your schedule.
3. Size of provider network: some dental insurance providers have a large network of dental providers, while others have a smaller network. This has to be taken into consideration, particularly when thinking of specialists (such as root canal specialists, gum specialists, and so on). Having a very small set of options might really limit the usefulness of the plan. Furthermore, if there is a specific dentist you want to be treated by, and he does not appear in the list, then it might be a good idea to look at a different offering – regardless whether the plan is PPO or HMO.
4. Customer Service/paperwork required: Paperwork
Nearly all dental insurance policies will request you and your dentist to fill a number of forms, every time they have a claim. Ask for more details if you want to avoid a time consuming claims process. It may go without saying but how fast and how easy it is for you to reach a representative may be indicative of how fast your claims will be processed. Does the insurance company have electronic claims filing capability to speed up the process? It is taken for granted often, but the patients are responsible for filing their dental claims! When an insurance claim is filed by a dental office, it is a courtesy that is extended by that office for the patient. In rare instances, if the insurance company proves to be unreliable and slow in their reimbursement for services rendered, the patient may be asked to pay up front and then be reimbursed by the office if and when the insurance company pays the claims.

Next, look at what is offer in the individual plans:

1. Monthly premium
The cost you have to pay for your insurance is always important. But keep in mind that the lowest price is not always the best price. Never choose the lowest cost plan before examining all the other factors described in this page.

2. Treatments covered

a. Basic dental care and procedure: This may include tooth extractions, fillings and other such procedures. Some providers may also include root canal in their basic dental care plan and some may not. What one provider covers will differ from what another provider covers.

b. Major dental care: Includes services like orthodontics, denture work, dental surgery and other such dental procedures. Not all dental insurance plans may cover the major dental care. However, some insurance companies may cover at least a portion of these costs.

c. Preventive and diagnostic care: Basic preventive dental care is covered by almost all dental insurance policies. This means that most of the dental plans cover a large part or may be all of the dental care costs for basic services. Such services include cleanings, check-ups and other such dental procedures. This coverage encourages patients or all those who are insured to seek regular dental check ups. Regular check ups in time can help prevent problems in the future.

All normal dental procedures, such as 6 month cleanings, dental fillings, root canals, in-depth check-ups, x-rays should, ideally, be fully covered under your plan. Most insurance plans do not cover cosmetic dental procedures. Other procedures like braces may be covered from some policies but up to a certain limit. Coverage of certain procedures such as implants and braces may justify a higher monthly premium. Learn exactly what is covered before making your decision.

Its GOOD TO KNOW:

a. Whether you get 2 exams and cleanings per year (which means you can go anytime) or once every 6 months (so you have to pay for any visit between the last visit and 6 months).

b. Is there a “least expensive alternative treatment” (LEAT), also known as the least expensive professionally acceptable treatment clause? This is the most common clause used by dental insurance companies to allow them refuse to pay for expensive treatment that you may need. Under a LEAT clause, when there are multiple viable options of treatment available for a specific condition, the plan will only pay for the least expensive treatment alternative.
For example, a composite (tooth colored) filling may be only covered as an amalgam (silver-mercury) filling, or an all-ceramic (zirconia/ non metal) crown may be covered as a porcelain-fused-metal crown with base metal content (which may be allergenic to your body). In these instances you may have to pay the difference between the two costs.

c. Is there a Missing Tooth Clause in which the insurance company will not cover for the replacement of any tooth you have lost before this insurance policy is effective.

3. Maximum annual limit
The majority of dental insurance plans cap the amount of reimbursement to an annual maximum that is usually $1,000 to $1,500 per year. You will be responsible for any costs beyond that amount. Some insurance providers offer special plans with higher annual limits up to $3,000, which despite their higher premium may be more suitable for individuals with bad dental health or require orthodontic work. Some plans have a limit not only in the amount covered but also in the number of certain procedures allowed per year.

4. Deductible
Usually, insured individuals must meet their deductible before the dental insurance company begins to cover their dental care, so the cost of deductibles should be considered when calculating the overall costs associated with dental insurance. Annual deductibles can vary from $25 to $50 per covered individual, depending on the dental insurance policy.

Be aware of insurance fraud traps. There are dentist and patients who asked for an arrangement for the dentist to waive the patient’s co-pays and deductibles, and in return, the dentist would bill the insurance companies for a variety of procedures not rendered to max out the patient’s annual limit. This is an issue that may hold severe consequences to both patients and dentists.

5. Waiting period
Dental insurance plans have exclusions on pre-existing conditions or impose long waiting periods from 6 to 18 months before paying for major dental treatment. This could be a serious problem if you need some serious dental work in the near future.

6. Special terms
UCR (Usual, Customary & Reasonable) indemnity dental insurance plans will check the cost of your treatment against the average cost from other similar treatments in their database. If the cost of your treatment is lower than average you will receive the agreed percentage of the amount you paid. If you paid more than the average you will have to pay the additional cost on your own.

7. Choice of dentist
Make sure that the dental insurance plan allows you to choose your own dentist. Many plans will force you to choose one of the dentists participating in their own network. Even though insurance providers claim that they work only with the best quality dentists, you might not feel comfortable with the proposed dentist.


8. Family members covered
If you have a family you should choose a family plan. Ask how the various restrictions (deductible, annual limit etc) are implemented; by individual member or in total. If you have children check if fluoridation, sealants or braces are covered.