Dental Insurance Plans: What’s Covered, What’s Not

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What’s Covered, What’s Not

If you have dental benefits, do you know what’s in the fine print and what type of plan is best for you?

Many Americans — 77% — have dental benefits, the National Association of Dental Plans says. Most people have private coverage, usually from an employer or group program. Large employers are more likely to offer dental benefits than small employers and high wage workers are more likely to receive them than low wage workers. Medicare doesn’t cover dental care, and most state Medicaid programs cover dental care only for children.

To make the most of your benefits, you need to know these things.

Insurance or Benefits?

When shopping for insurance, you may see the term dental benefits, which is different from insurance.

An insurance plan is meant to absorb risk — the risk that you’ll need to have a tooth pulled, for instance, or to get a root canal — and covers costs accordingly.

A benefits plan covers some things in full, but other things only partially, and others not at all. It’s meant to be helpful, but it’s not a catch-all.

When you shop for coverage, make sure you understand what the plan covers.

Dental Plan Categories

Although the features of plans may differ, the most common designs can be grouped into the following categories:

  • Direct reimbursement programs pay patients a predetermined percentage of the total amount they spend on dental care, regardless of treatment category. This method typically does not exclude coverage based on the type of treatment needed, allows patients to go to the dentist of their choice, and encourages them to work with the dentist toward healthy and economically sound solutions.
  • “Usual, customary, and reasonable” (UCR) programs usually allow patients to go to the dentist of their choice. These plans pay a set percentage of the dentist’s fee or the plan administrator’s “reasonable” or “customary” fee limit, whichever is less. These limits are the result of a contract between the plan purchaser and the third-party payer. Although these limits are called “customary,” they may or may not accurately reflect the fees that area dentists charge. There is wide fluctuation and lack of government regulation on how a plan determines the “customary” fee level.
  • Table or schedule of allowance programs determine a list of covered services with an assigned dollar amount. That amount represents just how much the plan will pay for those services that are covered, regardless of the fee charged by the dentist. The difference between the allowed charge and the dentist’s fee is billed to the patient.

Capitation programs pay contracted dentists a fixed amount (usually on a monthly basis) per enrolled family or patient. In return, the dentists agree to provide specific types of treatment to the patients at no charge. (For some treatments, there may be a patient co-payment.) The capitation premium that is paid may differ greatly from the amount the plan provides for the patient’s actual dental care.