Dental insurance encourages preventive dental care, which saves an estimated $4 for every $1 spent by eliminating the need for expensive, invasive and painful procedures.
The Affordable Care Act requires all new (non-grandfathered) health insurance plans in the individual and small employer markets to include dental coverage for children age 18 and younger as an “essential health benefit.” This means if you’re getting coverage for someone 18 or younger on an individual or small group plan, dental coverage must be available as part of the plan or in a stand-alone plan.
Although the health care reform law requires most people to have health coverage or pay a penalty, this doesn’t apply to dental coverage. Although insurers must make dental coverage available to individuals age 18 or younger, you don’t need to have dental coverage, even for children, to avoid the penalty.
Even if you don’t need dental insurance to avoid penalties under the Affordable Care Act, dental insurance helps many people afford expensive dental care.
Most dental insurance plans cover:
• Twice-yearly cleanings and exams
• Annual x-rays
• Restorations (fillings and crowns)
• Periodontics (treatment of gum disease)
• Endodontics (root canals)
• Bridges and dentures
Some also cover orthodontics. Many dental insurance plans let you see any dentist, while some use a network of dentists.
Most insurers offer managed care plans designed to encourage wise use of dental benefits, with lower out-of-pocket costs for preventive services such as exams, x-rays and cleanings. Many plans also offer benefits for orthodontics, but pay a lower percentage for orthodontics than for restorative services such as fillings, root canals, etc.
Dental Plan Options
Indemnity Plans
Under this “traditional” insurance plan, the plan pays dentists according to a formula—usually a percentage of the dentist’s fee, up to a “usual and customary” maximum. The dentist can bill insureds for the difference, or copayment. Most plans also have patients pay a deductible per visit or per series of treatments as well.
HMO
Dental health maintenance organizations
In an HMO, dentists agree to provide specified dental services to members in return for a periodic per-capita payment—usually monthly. Payments do not depend on the number or type of services rendered, and the HMO accepts the financial risk for providing covered dental services to members.
Most plans require participants to use an HMO dentist, but some plans provide reduced benefits for members who use out-of-network dentists. A participant may have to pay a deductible, co-payment, or any amount exceeding plan coverage levels.
PPO
Preferred Provider Organization
A dental PPO consists of a network of providers who agree to accept a certain discounted payment for their services. PPO plans give insureds financial incentives to use these “preferred providers” by paying higher percentages of claims they submit than for those submitted by non-preferred providers. Insureds pay the uncovered portion out of pocket.
