What Dental Insurance Coverage do I have
and What Dental Plan Coverage do I Want?
It's Important To Put Your Money Where
Your Mouth Is
When most people think about health
insurance, they think first about covering costs of treatment for serious
medical conditions or accidents. That's a natural thing to do. But there's
another type of insurance that's equally important to your well-being --
dental insurance. Because dental disease is so common, being protected by
dental insurance and using it wisely are essential safeguards for you and
There's A World Of Difference Between
Medical and Dental Disease...
Unlike medical disease, which can be both
unpredictable and catastrophic, most dental ailments are preventable.
Preventive care, including regular checkups and cleanings, is the key to
maintaining your oral health. With regular visits to the dentist, problems
can be diagnosed early and treated without extensive testing or elaborate
and expensive procedures. That keeps the costs of dental care much lower
than those of medical care. In fact, total spending for dental care is
decreasing. In 1970, it made up 6.3 percent of total healthcare
expenditures. But in 1991, dental care's share of health care spending was
only 4.9 percent.
...And Between Medical and Dental
Medical insurance is designed primarily to
cover the costs of diagnosing, treating and curing serious illnesses. This
process may involve a primary care physician and multiple specialists, a
variety of tests performed by doctors and laboratories, multiple procedures
and masses of medications. Depending on the health, age and attitudes of
people in the medical coverage group, costs can fluctuate widely.
Dental insurance works differently. Most
dental coverage is designed to ensure that the patient receives regular
preventive care. High quality dental care rarely requires the complex,
multiple resources often required by medical care. A thorough examination
by the dentist and a set of x-rays are all it usually takes to diagnose a
problem. By and large, dental care is provided by a general practitioner,
although some cases may require the services of a dental specialist.
Because most dental disease is preventable, dental benefits plans are
structured to encourage patients to get the regular, routine care so vital
to preventing and diagnosing the onset of serious disease.
In fact, most dental benefits plans
require patients to assume a greater portion of the costs for treatment of
dental disease than for preventive procedures. By placing an emphasis on
prevention, and by covering regular teeth cleaning and check-ups, Americans
saved nearly $100 billion in dental care costs during the 1980's.
Dental Insurance Is Helping Keep America
The availability of dental insurance is
the single greatest factor in helping you get the dental care you need.
More than 48 percent of all Americans -- 113 million of us -- are covered
by privately financed dental insurance plans. This compares with just 12
million people who had such coverage in 1970. As a result of increased
access to regular care and the widespread use of preventive measures, the
incidence of dental decay has dropped sharply. Half of today's school
children never have had a cavity.
Different Plans For Different Needs --
Know the Differences
Consumers can choose from an assortment of
dental benefits plans that accommodate a variety of needs and expectations.
The following factors differentiate one plan from another:
- 1. The type of third party responsible
for funding and administration of the plan;
- 2. The alternatives offered for
selecting a dentist;
- 3. The structure used to compensate the
dentist for services provided; and
- 4. The method by which benefits and
payments are calculated.
Understanding these differences is
essential to making an informed decision when selecting a plan and using
1. Third Parties
Regardless of the dental benefits plan,
there are usually three parties involved: you, the patient; the dentist
providing care; and a third party with whom you or your employer contracts
for coverage. If your options include a plan funded by your employer, you
may have an administrator responsible for processing and payment of claims.
The primary responsibility of the third party is to provide the financial
foundation for your dental benefits plan. There are three types of third
2. Choosing A Dentist
Dental benefits plans can be categorized
by the options offered for selecting a dentist. Some plans allow you the
freedom to choose your own dentist, while others, in exchange for lower
rates, limit your choice. These two alternatives are called open and closed
3. Paying The Dentist
When choosing a benefits plan, it is
important to know who pays what to whom. Dental plans can be categorized
into three types based on the compensation and treatment provided.
4. Calculating Payments
A clear understanding of the methods used
to calculate benefits and payments will allow you to compare and evaluate
the purchasing power of different plans. The following are four common
Patients should understand that
contracted fee reductions listed in some plan allowance schedules can
significantly diminish the level and quality of care delivered. Contracted
rates are based on the size of the patient population and projections of
the amount and type of treatment performed within a given time frame. Since
cost control drives this payment approach, your ability to choose your
dentist or see a specialist may be limited.
Dental Plans Do Have Their Limitations
Today's health insurance, including your
dental plan, is designed to help you get the care you need at a reasonable
cost. Because each person's oral health is different, costs can vary
widely. To control dental treatment costs, most plans will limit the amount
of care you can receive in a given year. This is done by placing a dollar
"cap" or limit on the amount of benefits you can receive, or by restricting
the number or type of services that are covered. Some plans may total
exclude certain services or treatment to lower costs. Know specifically
what services your plan covers and excludes.
There are, however, certain limitations
and exclusions in most dental benefits plans that are designed to keep
dentistry's costs from going up without penalizing the patient. All plans
exclude experimental procedures and services not performed by or under the
supervision of a dentist, but there may be some less obvious exclusions.
Sometimes dental coverage and health insurance may overlap. Read and
understand the conditions of your dental plan. Exclusions in your dental
plan may be covered by your medical insurance.
The Dental Consumer Advisor encourages
consumers to choose plans that impose dollar or service limitations, rather
than those that exclude categories of service. By doing so, you can receive
the care that's best for you and actively participate with the dentist in
the development of treatment plans that give the most and highest quality
To help you stretch each dental benefit
dollar, most plans provide patients and purchasers with special
administrative services. Find out if your plan provides the following
mechanisms to help you budget, analyze and dispute, if necessary, the costs
of your dental care.
Eight Things To Consider When Choosing
Your Dental Plan
What looks like a bargain today may not be
a good buy in the long run. While your out-of-pocket costs are, of course,
an important part of your decision-making process when choosing a dental
plan, they are not the only criteria to use when evaluating your options.
Your primary focus should be to determine whether the coverage will satisfy
your dental care needs. Consider the following:
Every dental care plan is different. It's
your responsibility to be informed about what your specific plan will
cover. As a basis of comparison, the following services should be covered
in full, with no deductible or patient co-payment:
Initial oral examination --- once per
Recall examinations -- twice per year
Complete x-ray survey -- once every three
Cavity-detecting bite-wing x-rays -- once
Prophylaxis, or teeth cleaning -- twice
Topical fluoride treatment -- twice per
Sealants -- for those under age 18
Restorative care -- amalgam and
composite resin fillings and stainless steel crowns on primary teeth
Endodontics -- treatment of root
canals and removal of tooth nerves
Oral surgery -- tooth removal (not
including bony impaction) and minor surgical procedures such as tissue
biopsy and drainage of minor oral infections
Periodontics -- treatment of
uncomplicated periodontal disease including scaling, root planing and
management of acute infections or lesions
Prosthodontics -- repair and/or
relining or reseating of existing dentures and bridges
Understand what routine dental care is
covered by the plan, and what percentage of the costs will come out of your
Restorative care -- gold
restorations and individual crowns
Oral surgery -- removal of impacted
teeth and complex oral surgery procedures
Periodontics -- treatment of
complicated periodontal disease requiring surgery involving bones,
underlying tissues or bone grafts
Orthodontics -- treatment including
retainers, braces and/or diagnostic materials
Dental implants -- either surgical
placement or restoration
Prosthodontics -- fixed bridges,
partial dentures and removable or fixes dentures
Getting The Best And Most From Your Plan
To take full advantage of your dental
benefits plan, visit the dentist regularly and get the preventive care that
will keep your mouth healthy. Follow the treatment plan you and your
dentist have developed. Do your dental homework -- brush and floss
regularly and maintain a regular schedule of oral examinations and teeth
Should you need treatment for particular
conditions, follow the procedure for predetermination required by your
plan. Find out what your insurance will cover. Feel free to discuss a
payment plan with your dentist for your portion of the treatment costs.
Making An Informed Choice
The law mandates that consumers with
dental coverage receive a fully detailed patient information handbook -- a
Description of Benefits -- that clearly outlines coverage, limitations and
exclusions. Before selecting a plan that best suits your needs, ask your
carrier or company benefits coordinator for a copy of the benefits
handbook. If you have questions about coverage, exclusions, calculation of
benefits or payment of benefits, ask before making your plan selection.
Find out which plans your dentist participates in and why. That's the best
way for you to get care from the dentist of your choice, and still take
advantage of the cost savings due to you.
Selecting an insurance program wisely
isn't simple. But having the facts to make an informed decision can make a
difference. No plan is perfect; each has its advantages and limitations.
Read the fine print. And by all means ask questions. The more you know
about dental benefits, the better equipped you will be to select the best
coverage for your dental health.
The following was taken from the
booklet "What Everyone Should Know About Selecting and Using Dental
Benefits." A Consumer's Guide to Dental Insurance, published in the public
interest by the California Dental Association.