The Ultimate Guide to Dental Insurance
Many people have dental insurance, but many people are also confused by how it works. Also, some companies offer more than one plan, and deciding between your choices can be very difficult. So, let’s break down dental insurance so that you, as a consumer, can be as knowledgeable as possible.
First, let’s start with where you can get dental insurance from. Usually it breaks down to two choices:
1- Your employer provides it as a benefit. The employer sometimes pays for the whole thing as a benefit, or part as a benefit, or simply allows you to buy it through their group so you get a discount.
2- You purchase it yourself on the open market. There are a couple dental insurance companies that offer individual plans. They are typically expensive to purchase yourself.
Next, let’s examine the different types of dental insurance.
1- Dental indemnity plans. This is just straight dental insurance. There are no networks, you can use it at any dentist. There will usually be a breakdown of benefit types and percentages covered. For instance, 100% payment on “preventive” services (cleaning, exams, x-rays), 80% payment on “basic” services (fillings, root canals, extractions), and 50% on “major” services (crowns, implants). They typically have a yearly maximum in the range of $1500–2000. These are the best plans, but also the most expensive.
2- Preferred provider, or “PPO” plans. These plans will have a breakdown of benefits similar to indemnity plans. However, the major difference is that they have a “preferred provider” network. What is a “preferred provider”? That is a dentist who has agreed to a reduced fee in exchange for being listed in the network. As good as “reduced fee” sounds to a patient, it can also cause problems that we will discuss later. Most PPO plans do allow patients to go to a dentist who is NOT in the network, but the patient often pays more. They typically have a yearly maximum in the range of $1500–2000.
3- DMO plans. These plans are set up differently than any other insurance. In a DMO, a patient has to “sign up” for a particular office that is on the plan. That is where you HAVE TO GO, until you notify the insurance company that you want to change (and jump through some hoops to do it). That office then gets a monthly payment for all the patients on their list. How much? Usually about $3 per patient, per month. Also, there is a list of co-payments for different procedures. These are MAJOR problems that we will discuss later.
So what are the pros and cons of each plan?
1- Indemnity plans:
Pros- They cover the most of all the plans and they also allow you to go to any dentist YOU choose with no penalty.
Cons- They are the most expensive to buy. For the average patient, unless you have an employer paying at least part of the premium, you will pay more than you would if you simply paid all of your dental bills out of pocket.
2- PPO plans:
Pros- They usually provide good benefit percentages.
Cons- In order to provide the maximum benefit, you have to go to a “preferred provider” (a dentist who has signed a contract with the insurance company to accept a lower fee). Why is this considered a “con”? Well, the answer is part economics and part human nature. Most dental offices run on an overhead of about 60–70%. Most PPO contracts cut dentist fees by 40–50%. This means that the dentist is getting paid less than it costs them to do the procedure. So, here is how human nature handles the economics of taking a loss on your procedure:
A- See more than one patient at a time (double booking, hopping from room to room). This results in less care and attention to detail on YOUR procedure.
B- Use cheaper materials and labs. Not all dental materials are created equal. Some work better than others. For instance, if you were having a sidewalk placed at your house, would you pay a little more for EP Henry pavers? Or would you let the contractor use a brand you never heard of?
The problem with cheap dental labs is that they all accomplish a lower price the same way- offshoring. Many dental crowns are made in South America, China, or Vietnam. Remember the big deal in the news a few years ago about dogs getting sick and dying from Chinese dog treats contaminated with lead? Chinese made crowns have the same problem with lead contamination. Quality control is also lacking in crowns made outside the U.S.A.
C- This is the tough one, but it happens. Treatment planning more or bigger (more expensive) procedures than you really need so the bill is larger for each appointment. It doesn’t happen all the time, but sometimes it does. This is especially true at chain dental offices where the doctor is not the owner, but an employee of the corporation.
3- HMO plans:
Pros- They are the cheapest plan out there. That’s really the ONLY pro!
Cons- Because they only pay the dentist about $40 per year, there is a real incentive to NOT provide regular preventive care. Think about it. The average fee for exam, check up x-rays and cleaning is around $200. So, it takes 5 years for the dentist to get the money for ONE check up and cleaning visit from the insurance company. They don’t want you coming in every 6 months! Also, most procedures have a copay that is more than what you would pay with a PPO plan. So, the incentive is there to wait for you to come in with a toothache and do a major procedure that you have a large co-payment for. HMO offices do a lot of what is called “upselling” as well. Let’s say you need a crown, and the co-pay is $700. They will “upsell” $100 for an “esthetic” crown (the ones your insurance pay for don’t look good, they will say). They will “upsell” you $100 for something else, and before you know it, you are almost paying completely for the crown out of pocket.
So, what should you, the consumer/dental patient do?
1- Choose a dental office based on recommendations of family/friends and always check their online reviews. That will give you an idea of how you will be treated there. Don’t go by whether the doctor is on your insurance company “list”.
2- If you have a PPO, don’t be afraid to go to an out of network dentist. Most of the time, the difference between what you pay in network vs out of network is not very significant. This is important because one of the big features of being a contracted, “preferred provider” is that the insurance company has more control over what procedures the dentist does. This usually does not benefit the patient.
3- Make sure your dental office is up front and transparent about your treatment plan and it’s cost. You should be told the total fee (not just your co-payment) of all the treatment you need.
4- Remember one very important fact when dealing with your dental insurance. They are NOT a benevolent third party trying to make sure you get excellent dental care. There are three people involved with your dental care- you, your dentist, and the insurance company. You and your dentist are concerned with things like “How long will the treatment last”, “Will it look natural”, “Will it take care of the problem I am having”, etc. The ONLY thing the insurance company cares about is how they can get away with paying as little as possible. They care only about their stockholders and profit. Last I checked I don’t know a single dentist with their name on top of the tallest building in the city. But, there are plenty of insurance companies with that honor.
I hope this has been informative. If you are unhappy with your current insurance, most employers have an enrollment period when you can switch. Just make sure you contact your dental office to discuss any new insurance before you switch. HR departments often only know what the insurance company tells them about a plan, not necessarily what it REALLY covers.
If you have any further questions, you can email us at info@DayspringDentalTwp.com
Or call 856.875.8400
- Dr. Matt Bickel