Dental insurance is designed to pay a portion of the costs associated with dental care. There are several different types of individual, family, or group dental insurance plans grouped into three primary categories: (1) Indemnity (generally called: dental insurance) that allows you to see any dentist you want who accepts this type of coverage; (2) Preferred Provider Network dental plans (PPO); and (3) Dental Health Managed Organizations (DHMO) in which you are assigned or select an in-network dentist and/or in-network dental office and use the dental benefits in that network.
Generally dental offices have a fee schedule, or a list of prices for the dental services or procedures they offer. Dental insurance companies have similar fee schedules which is generally based on Usual and Customary dental services, an average of fees in your area. The fee schedule is commonly used as the transactional instrument between the insurance company, dental office and/or dentist, and the consumer.
Indemnity Dental Insurance Plan: This plan may be helpful when you want to stay with your dentist and he/she does not participate in a dental network. By the very nature of this plan the insurance company generally pays the dentist a percentage of your services according to the policy you purchased. In addition you will want to review the co-payment requirements, waiting periods, stated deductible, annual limitations, graduated percentage scales based on the type of procedure and/or length of time you have owned the policy prior to starting your dental work.
Dental Health Managed Organization (DHMO): When a dentist signs a contract with a dental insurance company that provider agrees to accept an insurance fee schedule and give their customers a reduced cost for services as an In-Network Provider. Many DHMO insurance plans have little or no waiting periods, no annual maximum benefit limitations, while covering major dental work near the start of the policy period. This plan is sometimes purchased to help defray the high cost of the dental procedures. Some dental insurance plans offer free semi-annual preventative treatment. Fillings, crowns, implants and dentures may have various limitations.
Participating Provider Network (PPO). Depending on your specific plan, the PPO works similar to a DHMO while using an In-Network facility. However, it allows you to use an Out-of-Network or Non-Participating Provider. Any difference of fees will become the financial responsibility of the patient unless otherwise specified in your dental policy. As noted, some dental insurance plans may have an annual maximum benefit limit. Thus, once the annual maximum benefit is exhausted any additional treatments may become the patient’s responsibility. Each year that annual maximum is reissued. The reissued date may vary as a calendar year, company fiscal year, or date of enrollment based on your specific plan.
Dental insurance companies divide benefits, services, or procedures into categories and refer to them with American Dental Association (ADA) 3-4 digit code. As an example, Preventative and Diagnostic procedures often include exams (ADA code 0120), x-rays (ADA code 0210), and basic cleanings or prophylaxis (ADA code 1110). Basic procedures often include fillings, periodontics, endodontics, and oral surgery. Major procedures often are crowns, dentures, and implants. Procedures such as periodontics, endodontics, and oral surgery may fall into the Major category depending on your specific plan with specific fee schedules and co-payments.
The enrollment process varies but often members are assigned an identification or policy number. When dental treatment is rendered a claim for services is filed with the dental insurance company. Depending on the type of dental insurance policy you purchased some claims processing is handled directly by the dental office. Check with your dental insurance representative to determine the best suitable plan for you and your family.