What are Dental Benefits?

Many of our Colony Square Dental Associates patients are covered by a dental benefit plan – a contract between the insurance company and their employer, union, or association. As the New Year begins, the majority of these plans start the clock anew on their 12-month calendar maximums, while a few renew mid-year, on July 1st. As we begin each year, we are often asked how dental benefits work and how plan renewals impact out-of-pocket expenditures.


What is the difference between a dental plan and medical insurance?

It’s important to understand the difference between dental benefit plans and medical insurance coverage. Dental plans are benefit plans. Typically, they are an add-on benefit, similar to a vision plan, with a limited amount of dollars that will be paid out towards care in a 12-month time span. Unlike medical insurance, which may have limitations and coinsurance, but does not have a yearly limit, dental benefit plans place a yearly benefit limit – usually around $750 to $2500 per year. Most dental benefit plans have not changed these maximums in the past three decades.


Why do some dental plans pay more than others?

The contract, and associated premium payments, is determined by negotiations between an employer and the insurance carrier. The result – a unique benefit plan that will contain details such as the maximum allowable maximum per year, your deductible and what services are not considered until the deductible is met, what treatment is considered as a ‘covered expense’ or ‘eligible service’, and the amount or percentage per dental procedure code. What is common amongst the plans? They do not cover procedures that are considered cosmetic in nature; care that is not due to dental disease or trauma. And many plans also stipulate that it will only pay benefits for the least expensive alternative treatment for a condition, or deny coverage for conditions that existed before you enrolled in the plan. In addition to excluding elective dentistry or care of pre-existing problems, the majority of plans do not cover all dental procedures. While the carrier is not advising you that the care is not indicated or needed, it means that your employer has purchased a plan that does not cover the cost of providing care for these services. This serves to limit the insurance carrier’s liability. If you wish to determine your financial responsibility for care that you and your dentist deem necessary to preserve or restore your dental health, a predetermination of benefits can be sent to your insurance carrier for consideration.


Are there different types of dental plans?

Yes. Most plans are either a DMO (Dental Maintenance Organization) or PPO (Preferred Provider Organization). Patients under the umbrella of a DMO will select a primary care dentist for their dental care. If a specialist is necessary, the primary care dentist will make the referral. DMOs are often the least costly plans due to these constraints. A PPO typically offers more flexibility in selecting one’s dentist. The patient is able to select a dentist from the ‘preferred providers’ list, but does not have to limit himself or herself to exclusively receiving care at that office. These dentists have agreed to contract with the insurance carrier to accept a pre-negotiated fees for care provided.  However, the majority of PPO plans allow you to go outside of the network to see a dentist of your choosing. Benefits may differ when seeing an in-network vs. an out-of-network dentist.


To learn more about your dental benefits and the plan that your employer participates in, contact your HR departments at work, call your insurance carrier, or ask us. We’d be happy to work with you to understand your plan and maximize your dental benefits.

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