We are often asked, “What’s the best dental insurance to have?” Of course, the answer to that question would depend on many different things. More often than not I will tell patients that the best dental insurance is whatever is offered to you by your employer — even better if given a choice of plans.
When comes to defining dental insurance I would say that it is not really insurance. For some reason, someone had decided long ago to call it insurance. Dental insurance is more accurately a defined benefit rather than true insurance. A defined benefit has a limit to how much money can be paid out for a beneficiary within a specific time frame. So now that I have explained what dental insurance actually is, let us discuss the different types of dental benefit plans that are generally offered through employer groups and the pros and cons of each. Then I will discuss what patients have told me about getting dental insurance on their own because there is a difference.
There are a few different types of employee dental benefit plans. The first one is called an indemnity plan. Indemnity plans are usually the best type of plan to have. The pros of having indemnity plans are:
- You are free to see any dentist that you want.
- The plan will usually cover their portion of the fee filed by the dentist.
- There is only one con that I can think of for having this type of plan and that is cost. The monthly premiums for indemnity plans tend to be higher than other plans.
The next type and generally the most common is the PPO plan. The PPO or preferred provider organization plan will provide the beneficiary with a list of doctors that are part of the plan. Sometimes there will be many choices of dentist to go to sometimes very few depending on how prominent the company that offers the plan is.
The pros of choosing a PPO plan are:
- Cost: a PPO plan is less expensive than an indemnity plan.
- Providers are not allowed to charge more for their service than what is stated on the EOB (explanation of benefits).
- Some PPO plans provide more in benefit dollars using an in-network provider than an out of network provider.
The cons of a PPO plan are:
- Limited choice in dentist providers
- Reduction of benefit dollars when using out-of-network providers.
- Limited types of procedure coverage.
- Higher copays when using out-of-network providers.
The next and final type of employee offered dental benefit plans are HMO plans. HMO plans assign you a specific office where the plan can be utilized. These offices tend to be very large, fast-paced and have many employees.
The pros of an HMO plan are:
1. Least expensive. That’s it.
The cons are:
- Can only go to one office to use the benefits.
- Very low reimbursement to providers may obligate them to try and upsell non-covered benefits to HMO-covered patients just so they can maintain a profit.
- A fast-paced setting makes it difficult to communicate with doctors or other staff.
- Large HMO-oriented practices tend to favor quantity over quality which can lead to long wait times.
- In severe cases, HMO-oriented practices that get paid on a capitation rate may have patients return several times to complete a procedure that can be completed in one appointment. As you can see avoiding HMO plans is probably the best thing to do.
In summary, dental insurance plans are defined benefits and not true insurance. More specifically, dental benefits will have an annual maximum benefit dollar amount. Indemnity and PPO plans will generally cover preventative care at 100%. This includes cleanings, exams, X-rays, fluoride treatment, and sealants. Even the preventative care that is covered will have limits. These usually are two cleanings per year, two exams per year, etc.
Other services are grouped into basic and major and a one-time annual deductible is usually applied when having a basic or major service. Basic services are things like fillings, periodontal treatment, extractions, and root canals. Major services are crowns, bridges, and dentures. Cosmetic services such as veneers or whitening treatments are never a covered benefit.
So then, is having dental insurance really necessary? The answer is no. I have had plenty of patients over the years retire or lose their dental benefits due to job changes or loss go out and try to find dental insurance on their own. The vast majority of the time these plans will have waiting periods of 6 or 12 months before they will cover any basic or major procedures. So that tooth that needs a filling might need a crown when the wait is over.
These individual plans also have very low reimbursement rates and patient copays are often high. Sometimes I see patients who need a lot of dental work go and purchase one of these plans because they believe they will be able to get all their work done. After taking their X-rays and completing the examination a treatment plan is given to them. Let’s just use round numbers to make this easy to make a point. Many times they will look at the treatment plan and they will frown a bit and look confused. The treatment to fix their teeth costs $7000 and their insurance is only going to pay $500 of that so their out-of-pocket is $6500.
Doesn’t make sense, does it? Most of the time it makes more sense to just pay what it costs and not even bother to have dental insurance. Our office offers dental membership plans for those who don’t have insurance but would like to have some type of dental coverage. These plans can be purchased for an individual, couple, or family of up to four people. For an annual membership fee you can get two cleanings, two examinations, unlimited X-rays, and 25% off of any treatment.