Some perspective from an insurance agent in the USA. Just note, I will not be recommending any specific insurance companies or organizations – just trying to share this for people that want to know more detail about dental insurance in this country. One other thing to note, things can vary widely by state or insurance policy so this is general information. If you have more specific questions about your policy consult your certificate of insurance or contact your plan’s customer service.
For people looking for information about what to do if you can’t afford a dental plan there are some suggestions at the bottom.
Health Maintenance Organizations (HMOs)
Key points:
- These plans require you to stay in a network of approved dentists/specialist for care to get services covered.
- In most cases, you have to advise the insurance company who your primary/general dentist will be. (If you don’t have a current dentist or your dentist is not in network you may be required to pick an in-network dentist at the time of enrollment.)
- Plans normally have low monthly premiums, low copays and co-insurance amounts, no waiting periods for most services and no annual out of pocket maximums.
- Typically, these plans are only offered in larger suburban/urban areas. If you live in a rural area with fewer residents (and few dentists) these plans may not be available.
Pros and Cons of HMOs
If you anticipate that you will need a lot of dental work, want a low costing plan and already have a dentist in-network then this may be an option for you. In a situation like this, your in-network dentist will accept the contracted amount the insurance plan will pay for services and you will pay a fixed copay or percentage of the cost (The amount depends on the type of service, a cleaning could be a $5 copay, crowns could cost up to $300 each as an example.). Most plans have no waiting periods so if you need immediate treatment for things like crowns or prosthodontics the majority of the cost would be covered by the HMO/waived off by the dentist. (If you are looking into implants, most HMOs do not offer coverage for implants.)
However, these plans come with draw backs. The amount the insurance company pays the in-network dentists is typically lower than what other insurance policy types would pay and lower than what a dentist would charge an uninsured person. If you were wondering why you have to register your general dentist, this is where that comes into play. The in-network dentists for some HMOs have signed a contract with your insurance company in exchange for being assigned a list of patients. Each month the in-network dentist will get a check for a small amount for each patient on that list, even if they don’t see the patient that month. This is supposed to help compensate for the lower payments for services, but as you can probably guess, dentists may still just end up breaking even or losing money for services rendered. This is why many dentists do not accept HMOs or will only accept a limited number of patients at a time from these insurance plans.
(Side-note: The following could apply to dentists in
HMO, PPO or other insurance networks. If you are going to attempt to find an in-network dentist please do your research on the dentist/practice before agreeing to treatment. There are good dentists that participate in networks but be wary. There are some untrustworthy dentists (especially ones that work at dental franchises/chains) that take these plans and will recommend doing unnecessary work to make up for the small payments they get from the insurance company.
Random Fact: Aspen Dental, Alpine Dental, Absolute Dental, etc. are examples of dental franchises. Ever wonder why their names start with A? When people used phone books, I know unheard of now, their goal was to be listed first in the directory for dentists.)
Preferred Provider Organizations (PPOs)
Key Points:
- PPOs allow you to see dentists that are in the network or out of network. However, you may be balance billed if you dentist out of network. (more on that below)
- PPOs have moderate/high monthly premiums, annual out of pocket maximums and may have waiting periods for some services.
- Most PPO plans follow the 100/80/50 rule.
Pros and Cons of PPOs
PPOs typically have a moderate to high monthly premium. If your plan is provided by your employer, the employer usually pays for a portion of your premium on your behalf. If you are trying to buy a PPO dental insurance policy on an individual basis you may find in some cases the premiums are 30% or more higher than the employer plan premium for the same coverage for this reason.
What do PPOs cover? Each plan may cover services at different percentages but they normally follow a similar structure. The 100/80/50 rule breaks down like this:
The plan covers 100% of the charges for preventative services (cleanings, xrays, exams, some plans may cover this at less than 100%)
80% coverage for routine work, you pay the remaining 20% (fillings for example but the services in this area can vary by policy)
50% coverage for major services, you pay the remaining 50% (oral surgery, root canals, for example but the services in this area can vary by policy)
On top of this, PPO plans usually have waiting periods. Again, this is not standard so it can vary but some policies may have waiting periods of six months, a year or longer for some services. This usually applies to things that fall in the “major services” area but some plans have a waiting period of 6 months for a filling. During the waiting period you are still paying the plan monthly premium and can have preventive services covered but any services that are part of the waiting period will not be covered until you have been in the plan long enough to satisfy the waiting period. (If you are wondering why waiting periods exist in these plans its so that someone can’t sign up for a month, get a new pair of dentures for example, and then drop out of plan only having paid the insurance company a fraction of the cost of the services.)
Another factor to take into consideration is the fact that these PPO plans have annual out of pocket maximums. Depending on the plan this can range from $1000-$2000. Unfortunately, this is the same annual out of pocket maximum that dental plans used to pay in the 1980s-1990s and has not kept up at all with inflation/rising costs. This means that you can max out your benefits fairly quickly if you need more than routine care in a given year. This is why some people see most PPOs as more like a dental discount plan. If your provider is in network the payment amount they are agreeing to is normally about 30% less than their usual going rate. With these types of plans it can be helpful to split up treatments if they are not critically needed. For example: if the PPO plan renews annually in January you could get treatment for preventive care and a crown in September (and probably max out your benefits for the year) and then have other services like fillings treated in the following February since your plan’s maximum will have reset for the new year in January.
One big difference between HMOs and PPOs is provider (aka dentist) options. With a PPO you can go to an in-network dentist or see a dentist that does not participate in the plans network. When your dentist is in network the dentist will accept the contracted amount as payment for their services and you pay a percentage for most services. (Since nothing is standardized with the plans, the cost of services can vary by provider and by state.)
Example: Charges are $100 for a filling, the PPO insurance has a contract to cover $80 for fillings. The PPO covers 80% of the $80 which is $63. This leaves $16 for you the patient to pay to cover the remaining 20%. Since in this example the dentist is in-network they will not charge for the $20 difference (the difference between what the dentist charged and what the plan was contracted to pay) and will accept $80 ($63 from insurance, $16 from you) as payment in full for the filling.
(Side note: When you see a new dentist with a PPO plan be sure to ask the office if they are part of your plan’s network if you are trying to cut down on costs. Many dental practice websites will say something to the effect of “we accept most insurance plans” but this does not necessarily mean they participate in your plan’s network. What this statement actually means is that the office will file the claim with your insurance on your behalf. Make sure you are clear on this before agreeing to treatment. Many dental practices will review this with you when going over the treatment plan. Some insurance companies will also let your dental office send their treatment plan to the insurance company before you start treatment so they can get an estimate of what they will be paid and what your out of pocket will be.)
If the dentist does not participate in your insurance policy network, they will take the payment from the insurance and bill you for the difference on top of any co-insurance left by the plan (this is called balance billing).
Example: Charges are $100 for a filling, the PPO insurance has a contract to cover $80 for fillings. The PPO covers 80% of the $80 which is $63. This leaves $16 for you the patient to pay to cover the remaining 20%. However, this dentist is not in-network so they will charge you an additional $20 to make up for the difference in what the insurance paid. In this case, the filling costs $20 + $16 = $36, compared to the same service costing $16 with the in-network dentist.
Affordable Care Act (ACA or Obamacare)
Key Points
- You cannot purchase a dental plan by itself from the ACA, you must also purchase your medical coverage through this program to get dental coverage.
- The ACA dental programs work like PPOs.
- Enrollment time periods are limited during the year unless you have some special qualifying event (marriage for example) or other situation that lets you enroll outside the annual enrollment period.
- It is possible to qualify for tax credits to help pay for the premiums for the insurance but this is based on your income and whether or not your current employer offers medical coverage to employees. (The tax credits could change or be removed at some point depending on the political climate)
- See the website for details based on your state at healthcare.gov.
(Side note about insuring kids: The ACA laws changed medical insurance polices so that if you have an employer sponsored plan, ACA or individual plan you can continue to claim your children as dependents until they age of 26, this used to stop at age 21. It may be good to keep your kids under your insurance policy while your kids are in college or finding their footing with a job that offers benefits.
Medicare
Key Points
- Provided by the federal government to seniors over the age of 65 and those with a legally recognized disability that prevents them from working.
- Original Medicare (Parts A and B) does not offer coverage for dental services. (Medicare was established before the need for preventative care was understood so dental, vision and hearing care were left out in the cold.)
- Some Part C Medicare advantage plans offer dental riders that can be added on to plans for an extra fee. Pay attention to the rider benefits, some of these riders only help cover preventative services.
- To get dental coverage, seniors or people with a disability, can buy a dental only insurance policy directly from an insurance company (the plans will work like HMOs or PPOs).
- More information is available at medicare.gov
Medicaid
- Program provided on a state by state basis for people with low-income, children, pregnant women, the elderly, and people with disabilities.
- In most cases, Medicaid only offers dental coverage for people under the age of 21 through their CHIP program.
- Medicaid requires the use of in-network dentists.
- In general, Medicaid pays dentists less for services (like the HMO plans) so it can be difficult to find dentist that participate in this program.
- Coverage and guidelines can vary a lot for each state so look up your individual state at hhs.gov
Health Savings Account, Flexible Saving Account (HSAs/FSAs)
- An HSA is part of a high deductible medical insurance plan that some employers offer or that can be purchased through the ACA.
- Money can be set aside in an HSA to help pay for medical expenses (including dental services). If the funds are used to pay for medical/dental expenses you pay no tax on those funds. The HSA itself will work like a standard savings account at a bank and the money rolls over every year. The funds in the account can also be invested in the stock market.
- FSAs are provided by employers and allow you to defer part of your pay check into the FSA tax free.
- FSAs have more restrictions than HSAs but allow you to use the funds for dental expenses.
- See the links below for more information:
FSA: https://www.healthcare.gov/have-job-based-coverage/flexible-spending-accounts/
HSA: https://www.healthcare.gov/glossary/health-savings-account-hsa/
I have no dental insurance…
Check out the links below first for some good suggestions about where to start with finding low or no cost dental care.
Where can I find low cost dental care?
https://www.hhs.gov/answers/health-care/where-can-i-find-low-cost-dental-care/index.html
Free Dental Clinics in the US
https://www.dentalfearcentral.org/forum/threads/free-dental-events-and-help-in-the-us.26591/
Another option would be to make an emergency fund if you don’t already have one and aren’t in need of immediate care. This can be as simple as setting up a savings account (preferably a high yield or high APY account) where you can store some funds over time for a rainy day. The amount you set aside is up to you but I would suggest an amount that would be equal or greater to what you would be paying for a PPO dental insurance plan.
Finally, some dentist work on a sliding scale (charging based on your income), offer payment plans or use services like CareCredit. Some dentist will openly advertise these services but other times you may have to ask.
