2018 Guide To Dental Insurance
Are You Wondering How Dental Insurance Works? Has It Changed in 2018 Because Of The Affordable Care Act?
For many people, the idea of buying health insurance is daunting enough without worrying about optional features like dental coverage. If you don’t visit the dentist regularly, then you may not even think you need this type of insurance. However, buying protection for your teeth and gums can be a good investment in your overall health. In the following guide, we’ll give you some basic information on how dental insurance works and what you can expect when you choose a plan.
Medical vs. Dental Coverage
You might wonder how medical insurance differs from dental insurance. These two types of insurance share several common features:
Both types require a monthly premium, both cover a set number of services each year and both require beneficiaries to spend money on non-covered services. All insurance works on the premise that you’re protected “just in case.”
However, dental insurance differs from medical insurance in a few key ways:
- Dental insurance usually costs less in monthly premiums, but coverage isn’t as extensive as medical coverage.
- Dental insurers will cover preventive care and other services such as fillings, but there’s a lower annual maximum than there would be for medical claims. In other words, dental insurance doesn’t always guarantee coverage for certain procedures.
- With medical insurance, certain services are always covered without limitation; dental insurance may place a cap on how many treatments or services of the same type that you can receive.
It might seem like dental insurance isn’t a great deal on the surface, but this type of coverage has its benefits. Dental work tends to be more expensive and more immediately necessary than certain types of routine medical procedures. If you need a root canal, for example, then you can’t wait months without risking the loss of your tooth. Like vision insurance, dental coverage is completely optional but useful in preventing major crises later.
In the following sections, we’ll take a more detailed look at dental insurance, how this type of coverage works for the average beneficiary and how the new healthcare law affects your options for dental coverage.
What a Dental Plan Covers
The biggest difference between medical and dental coverage is that dental coverage places restrictions on the type of services it covers and the frequency with which you can receive treatment. If you break your leg, for example, then your medical insurer will cover a portion or all of the treatments necessary to get you back on track. You can break your leg several times a year, and your provider will continue to cover the treatments as long as you’re within your policy limits. Dental insurance works differently for a couple of reasons.
Here are the major classes of service covered by dental insurance:
- Class I: Preventive and diagnostic care is considered “class I.” Most dental plans fully cover semi-annual cleanings, routine X-rays and other services deemed to be preventive.
- Class II: Normal restorative care such as root canals or standard fillings count as “class II” services, and many plans cover 80 percent of the cost of these treatments.
- Class III: If you need a more invasive or intensive procedure such as crowns, this treatment counts as a “class III” service. Dentures also fall within this category, and most dental plans will pay 50 percent of the cost.
- Class IV: Class IV services specifically cover orthodontic treatments such as braces. Many dental plans place a separate coverage cap on orthodontic treatment, and some plans only offer coverage for braces for minors or younger dependents. Your plan may not cover orthodontia at all.
While most dental plans will cover at least the first three classes of service, some plans cover more services than others. For example, your plan might only include annual X-rays, full X-rays every five years or limited restorative treatments. Before you commit to a plan, check with providers to see what kind of limitations they place on frequency of care.
Three Types of Dental Plans
Like medical insurance, dental insurance offers different levels of coverage depending on the type of plan you purchase. For example, some medical plans may require you to use only in-network doctors when receiving treatments. Dental plans work the same way. There are three standard types of dental plans: a Dental Health Maintenance Organization or DHMO Plan, a Dental Preferred Provider Organizations or DPPO Plan, and a Dental Indemnity Plan. Below, we’ll briefly discuss the major features of these plans.
Dental Health Maintenance Organization or DHMO Plan:
- In a dental health maintenance organization plan, beneficiaries receive covered benefits for visiting in-network providers.
- You may not have an annual limit on coverage with this type of plan, and you’ll likely have lower out-of-pocket costs.
- DHMO plans work well if you want to avoid high out-of-pocket costs, but there are some limitations with these types of plans. For instance, you’ll usually have to use in-network providers in order to get your coverage. Out-of-network providers can charge full price for their services, and you may have to pay the entire cost.
- Also, you’ll have to see your primary dentist to get referrals if you need other dental services from specialists such as oral surgeons.
Dental Preferred Provider Organizations or DPPO Plan:
- In a preferred provider organization plan, you have greater flexibility in choosing your providers, but you’ll still gain the most benefit from seeing in-network professionals.
- Providers who participate in PPO plans agree to charge a set amount according to carrier requirements, which means that many preventive or routine services will be fully or mostly covered. If you go outside if your network, you’ll still get a reduced rate, but you’re more likely to pay higher fees plus any additional charges not covered by insurance.
- The upside to PPO plans is that your provider will typically handle the paperwork and claims process for you.
Dental Indemnity Plan:
- Not all dental providers operate within a network. If your dentist doesn’t participate in a larger network of providers or any particular plan, then a dental indemnity plan may work for you.
- In this type of plan, you’ll choose your coverage based on carrier. The insurer will then cover certain services based on what you chose.
- You’ll still have a deductible and co-insurance as with other plans.
You can also buy a dental plan called a discount dental plan, but it’s not actually considered insurance. These plans offer a discount on dental services according to a set rate schedule agreed upon by your provider. You can use discount dental plans on any service, cosmetic or necessary, but you’ll cover the cost entirely on your own. Your only discount will be the set price offered by your providers.
Paying for Dental Services
When you visit your doctor, you probably pay a set amount up front known as copay. This amount covers the cost of the visit unless you receive other services while you’re there, and you usually don’t have to pay more than $20. With dental care, you may or may not have copay when you see your dentist. However, payment for dental services works differently. In many cases, you may have to pay your dental office before you receive treatment. Once the work is done, your insurer will decide how much to reimburse you for the services.
Let’s take a look at an example to illustrate this point:
- Marcy needs a filling done, which is a class II service and covered at 80 percent by her insurer. Marcy has a PPO plan. She can choose which dentist performs the filling, but she’ll pay more for an out-of-network provider.
- The retail cost of the filling is $188. Marcy chooses an out-of-network dentist because she’s heard good reviews about him.
- Marcy’s insurance provider pays 60 percent of the $188 cost because the dentist is outside of the network, which equals $112.80. Marcy will have to pay the difference of $75.20 out of her own pocket for the filling.
- Even though Marcy’s out-of-pocket cost is relatively low, she’ll still have to pay the full cost of the filling before she gets the work done because that’s how her policy works. Out-of-network providers often charge the full cost beforehand.
Once Marcy gets the work done, her dental office will submit the claim for reimbursement for Marcy because she has a PPO plan, and most PPO plans take care of the paperwork for you. DHMO plans also usually take care of the paperwork. However, since she chose an out-of-network provider, Marcy may have to handle the claim on her own. Each dental practice has its own policies on filing claims.
Marcy could have saved even more money by using an in-network provider, but you don’t have to pick a dentist you dislike just to save a few dollars. When calculating cost, consider the providers available within your network and whether those providers have good reviews. The peace of mind that comes from choosing a quality dental provider can outweigh the higher price tag in some cases.
How the ACA Affects Dental Coverage In 2018
The Affordable Care Act requires all eligible American citizens to purchase minimum essential health coverage. This rule applies only to medical insurance. Dental and vision coverage are still optional under the law, and you won’t be penalized for neglecting to buy dental insurance. However, you might still wonder how the new law affects dental coverage. For instance, can you buy dental insurance on the marketplace along with your medical coverage?
In short, you can buy dental coverage on the marketplace provided that you meet one of two conditions:
- You buy the dental coverage as part of a medical insurance plan that offers dental insurance.
- You buy a standalone dental insurance plan in addition to medical insurance coverage.
If you visit HealthCare.gov, you can browse the medical plans that are available to you and check which ones offer dental coverage. Alternately, you can buy a standalone plan on the marketplace as long as you have a medical plan in place, or you can purchase a private plan off-marketplace. As an adult over the age of 18, you can only buy dental coverage on the marketplace if you meet either of the above conditions.
However, children don’t have to meet these rules to qualify for dental coverage. Under the ACA, pediatric dental care is included among the ten essential benefits provision. This means that all kids must have access to dental coverage within ACA-compliant plans. You don’t have to purchase dental coverage for your kids, but you have to be given the option with your medical coverage. You can choose to decline dental coverage for your kids if you want, but it’s a covered service under your medical plan thanks to the ten essential benefits provision of Obamacare. Still, there are no penalties for declining dental coverage under the new healthcare laws even for your kids.
How and Why to Buy Dental Insurance
The purpose of this dental insurance guide is to help you understand how dental insurance works. In this section, we wanted to mention briefly how to get dental coverage and why it might be a good idea for you. Good preventive care helps ensure that you don’t develop costly and unnecessary problems later in life. Dental issues can be astronomically expensive. A single crown, for example, might cost $1,200 in some areas. Insurance may only cover half of this cost, but this still saves you $600.
If you’re ready to get insurance, then you have several options. If your employer offers optional dental coverage, then enroll in a group plan, which may save you some money. Otherwise, take advantage of private plans available directly through your preferred carrier or a marketplace plan available on your state or federal health insurance exchange site.
Remember: Dental coverage is not required under the Affordable Care Act. However, you may find that investing a small amount each month for regular dental care helps keep you and your family healthier in the long run.