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Dental Insurance

Introduction FAQ's What I Think Examples + Analysis Final Word Definitions

We gladly accept and will file your claims for any insurance plan that allows you to choose any Dentist. If your plan is an HMO and requires you to visit a contracted clinic, it is unlikely we can accept your insurance plan. You can always contact us for more information.

The world of dental insurance can be dizzyingly complicated, even to someone such as myself that deals with the subject daily.  I have spent a great deal of time trying to create a page to help clarify dental insurance and offer some of my opinions. You can find definitions of many insurance terms at the bottom of this page.

FAQ's

CAN YOU RECOMMEND A PRIVATELY OBTAINED INSURANCE PLAN?
Dental insurance can be very limited in benefit, and privately obtained plans are typically the worst for the following reasons:

• Most are HMO's, which means you have to visit a contracted clinic, severely limiting your options
• If the plan lets you choose any dentist, it typically pays based on a fee schedule (<40% of the dentists' fee)
• Premiums at least $425 per year per person with yearly maximum payout of $1000
• 1-2 year waiting periods before the plan will pay for other than a portion of an exam, x-rays, and basic cleanings

WHY ARE SOME PROCEDURES NOT COVERED?
The benefits covered by your dental plan have been negotiated between your employer and the insurance company. There are tens of thousands of dental plans and it is impossible for a dental office to know details within all of them, and some insurance companies do not share the details with dental offices. You are the only one who has access to all of your dental plan's benefits.

WHY DID MY INSURANCE NOT PAY FOR A PROCEDURE THAT IS COVERED?
Insurance companies reserve the right to review all claims and make their own decision on whether to pay. This is a very sticky issue, and the source of much frustration in dentistry. In my opinion, when an insurance company denies a covered benefit, they are implying to know what is best for you, even though they have limited information on you. You are always welcome to dispute the insurance company's decision, but we have limited avenues and resources for such action.

IF I DON'T HAVE DENTAL INSURANCE, WHAT HAPPENS IF I GET IN AN ACCIDENT?
Don't mistake the need for medical insurance with a need dental - they are quite different. Believe it or not, many dental plans don't cover "accidents". I have a patient who fell down and broke three front teeth. Her dental insurance paid zero! Luckily, her medical insurance stepped up and covered most of the dental work. Even if your dental insurance does cover accidents, you have to remind yourself of the yearly maximum. No matter what dental care you require, your insurance will not pay more than that maximum (typically $1000-2000 per year). If your keeping dental insurance just in case you may need that $1000-2000 some day, you might want to look at your premiums and do some math.

IF I HAVE 100% INSURANCE COVERAGE, SHOULD I HAVE TO PAY ANYTHING?
Almost no one has 100% coverage for everything, though many people have 100% coverage for routine cleanings, exams, and x-rays. If your insurance implies 100% coverage for everything, it is actually 100% of the insurance company's "fee schedule", which is often 25-40% of the average dental fee.

DR. RAFF & MY HYGIENIST TELL ME THAT I NEED MY TEETH CLEANED EVERY 3 MONTHS, BUT MY INSURANCE WILL ONLY PAY FOR 2 PER YEAR. WHY IS THAT?
When we recommend treatment, we are only interested in what is best for your health. Remember, your plan is simply a contract of benefits negotiated by your employer and your insurance company for all employees. This is an issue between you and your employer. You must decide whether you want to let your insurance company dictate what treatment is done.

What I think

As with 80-90% of all dentists, our office does not participate in managed care because of the limitations those plans impose on the dentist and the patient. Our office does not believe offices that participate in managed care can provide quality comprehensive care for all patients.  I am not comfortable with a system which provides discounted care in exchange for a large volume of patients forced to visit an office.

As a consumer, I advise you not participate in plans that limits your choice of dentist.   If you have a list of dentists you must seek care from, you will not find our name on the list. 

What would you think if you were told your salary was being lowered to its 1970 equivalent? I have seen numerous dental insurance plans which have the same yearly maximum as they did in the early 70's. It's hard to believe, but it's true. Most dental plans offered a $1000 per year maximum in 1971.  At a 6% inflation rate, in 1998 it would have been $4550 per year.  In other words, back when cleanings were $8, plans were offering $1000 per year benefits, but now that cleanings are ten times that cost, you still only get $1000.

How I Think: Examples & Analysis

Federal Government Employee Example:

In 1999 I was asked by a close friend to help choose between 2 dental insurance plans offered by her employer, the Veterans Administration.  One plan ($120/year) made her choose from a small list of contracted dentists (i.e. a DMO/HMO), so we threw that out.  The second plan, through Delta Dental, ($240/year) allowed her to go to any dentist. That was out also, but lets see why:

This second plan paid based on a fee schedule. I calculated for 2 cleanings, checkup x-rays, and 1 exam, they only paid $94.  Those minimum yearly procedures cost about $215 in 1999.  My friend would pay $240 in premiums plus the $121(215 minus 94) the plan didn't cover, totaling $341/year for just 2 standard visits per year.  Then if you look at what they paid for fillings and crowns it was laughable.  She now pays for 100% of her dental bills, saving money every year.

Private Sector Example

A major pharmaceutical company offers its employees 3 dental plans (table below). None of the 3 plans have a deductible and you may choose any dentist.

To choose from these 3 plans I start with the fact that minimum preventive services per year in 1999 cost about $215 and that all 3 plans pay 100% of this.  Thus you certainly save money with the "Preventive" plan ($111/year premium).  

If you pay $129/year more for the "Standard" plan to add the 50% benefit for basic & major, it means to get that $129 you spent back from the insurance company  you need $258 in basic &/or major dental work on the average each year because they only cover 50% of it.  If you rarely need more than cleanings you may want to stick with the "Preventive" plan.  

For my friend, I recommended the "Comprehensive" plan because she typically has at least a filling each year.  For that additional $239/year premium she only has to pay 20% of fillings (80% insurance coverage).   To get that $239 back from the insurance she only needs $299 in basic &/or major.  

The bottom line is that this company has good dental coverage aside from the low maximums.

The final word 

To stand on my soapbox for a moment, there is no true dental insurance.  "Insurance" replaces what has been lost.  The reality is that an employer has negotiated a contract with a dental insurance company.  The insurance company's responsibility is not to properly remedy your loss, only provide what is in the contract.   Dental insurance can be a nice benefit as long as you know what you are getting.

For dental insurance to pay its contracted amount towards a procedure, you must meet all the following criteria:
1) The procedure is covered by your dental plan.
2) The insurance company approves the procedure. It's not always enough that the dentist says it is needed.
3) You have not reached your yearly maximum.
On the other hand, even if there is only 1 option to fix a dental problem and that option is not a covered benefit, your insurance pays nothing.

Specific questions regarding your insurance benefits are best and most accurately handled by your employer, insurance company, or your dentist.  In the end, you alone are responsible for understanding your dental insurance benefits. Good luck.

Definitions 

"Basic": 1 of the 3 categories that all dental procedures fall under.  "Basic" includes most fillings and typically root canals, oral and periodontal surgery.

Cafeteria Plan:  An employee's benefit plan that allows you to select benefits from a list of nontaxable options.  These options may be vision, medical, and dental.  The dental plan you may select is at the discretion of your employer.

Capitation Plan:  Capitation means "by the head." The contracted dentists must provide all, or most, of the dental services covered under that plan for a payment on a "per-patient" or "per-treatment" basis, regardless of what is performed.  Basically this is a variation of the DMO.

Dental Maintenance Organization (DMO):  Type of managed care plan whereby a listed/participating contracted dentist is paid a fixed monthly fee per patient on that plan. The listed dentist(s) must provide all covered services to patients on that plan for typically no additional fee from the insurance company or patient.  The participating DMO dentist can charge the patient their normal fee if the treatment is not a covered service but the patient has to pay 100% of that fee.

Direct Reimbursement:  A very simple and straight-forward dental insurance coverage concept. The plan is managed by the employer, not an insurance company. You have the freedom to choose any dentist for treatment. The plan reimburses the actual amount spent at the dental office, not based on the treatment. This style of dental insurance meets the fairness criteria recommended by the American Dental Association and myself. The ADA has setup an elaborate web site with more information on direct reimbursement at www.ada.org/dr.

Fee Schedule:  Where an insurance company has a specific fee they will pay for each procedure covered by a dental plan.  These fee should be found in a benefits booklet.  You may usually choose any dentist, but insurance will only reimburse that specific fee set by the insurance company and any difference the patient must cover.  Typically fee schedules are 15-35% of any "usual fee" and it is expected that a substantial portion of all treatment will paid directly by the patient.

Managed Care/Health Maintenance Organization (HMO):  Plans that control costs by restricting what office treatment may be administered, the frequency of treatment, and how much is paid towards the treatment.  A list of dentists contracted with this plan is who you must seek care from.  Premiums to the HMO are usually paid for by an employer at a fixed price per patient. Patients generally do not have any significant "out-of-pocket" expenses. You will not know the amount an HMO dentist is reimbursed by an HMO.  You cannot choose an office such as mine and utilize an HMO plan.  Less than 30% of all dentists in the United States participate in HMO plans.

"Major": 1 of the 3 categories that all dental procedures fall under.  "Major" includes crowns, bridges, dentures, and sometimes oral and periodontal surgery.

Preferred Provider Plan (PPO): Type of managed care plan that contracts with a group of dentists to provide treatment for discounted fees to people enrolled in the plan.  Covered patients usually must select a dentist from the PPO list, and they may or may not be able to switch dentists.  This sometimes is identical to Managed Care.

"Preventive": 1 of the 3 categories that all dental procedures fall under.  "Preventive" includes standard cleanings, x-rays, and exams.

Usual, Customary, Reasonable: Usual Fee is what an office charges for a procedure.  The Customary Fee is the amount the insurance company deems acceptable for a procedure.  My fees are nearly always within the usual and customary fee of insurance companies.