Dental insurance - individual and group dental plans

What do you look for in choosing a dental plan?

Does the plan give you the freedom to choose your own dentist or are you restricted to a panel of dentists selected by the insurance company? If you have a family dentist with whom you are satisfied, consider the effects changing dentists will have on the quality or quantity of care you receive. Because regular visits to the dentist reduce the likelihood of developing serious dental disease, it's best to have and maintain an established relationship with a dentist you trust.

Who controls treatment decisions--you and your dentist or the dental plan? Many plans require dentists to follow treatment plans that rely on a Least Expensive Alternative Treatment (LEAT) approach. If there are multiple treatment options for a specific condition, the plan will pay for the less expensive treatment option.

If you choose a treatment option that may better suit your individual needs and your long-term oral health, you will be responsible for paying the difference in costs. It's important to know who makes the treatment decisions under your plan. These cost control measures may have an impact on the quality of care you'll receive.

Does the plan cover diagnostic, preventive and emergency services? If so, to what extent? Most dental plans provide coverage for selected diagnostic services, preventive care and emergency treatment that are basic for maintaining good oral health.

But the extent or frequency of the services covered by some plans may be limited. Depending upon your individual oral health needs, you may be required to pay the dentist directly for a portion of this basic care. Find out how much treatment is allowed in any given year without cost to you, and how much you will have to pay for yourself.

Initial Oral Examination----once per dentist
Recall Examinations----twice per year
Complete x-ray survey----once every three years
Cavity-detecting bite-wing x-rays----once per year
Prophylaxis or teeth cleaning----twice per year
Topical Fluoride treatment----twice per year
Sealants----for those under age 18

What routine corrective treatment is covered by the dental plan? What share of the costs will be yours? While preventive care lessens the risk of serious dental disease, additional treatment may be required to ensure optimal health. A broad range of treatment can be defined as routine. Most plans cover 70 percent to 80 percent of such treatment. Patients are responsible for the remaining costs. Examples of routine care include:

Restorative care - amalgam and composite resin fillings and stainless steel crowns on primary teeth
Endodontics - treatment of root canals and removal of tooth nerves
Oral Surgery - tooth removal (not including bony impaction) and minor surgical procedures such as tissue biopsy and drainage of minor oral infections.
Periodontics - treatment of uncomplicated periodontal disease including scaling, root planning and management of acute infections or lesions
Prosthodontics--repair and/or relining or reseating of existing dentures and bridges.

What major dental care is covered by the plan? What percentage of these costs will you be required to pay? Since dental benefits encourage you to get preventive care, which often eliminates the need for major dental work, most plans are not generous when it comes to paying for major dental work, most plans cover less than 50 percent of the cost of major treatment.

Most plans limit the benefits--both in number of procedures and dollar amount--that are covered in a given year. Be aware of these restrictions when choosing your plan and as you and your dentist develop treatment best suited for you. Major dental care includes:

Restorative care--gold restorations and individual crowns
Oral Surgery--removal of impacted teeth and complex oral surgery procedures.
Periodontics--treatment of complicated periodontal disease requiring surgery involving bones, underlying tissues or bone grafts.
Orthodontics--treatment including retainers, braces and/or diagnostic materials.
Dental Implants--either surgical placement or restoration
Prosthodontics--fixed bridges, partial dentures and removable or fixed dentures.

Will the plan allow referrals to specialists? Will my dentist and I be able to choose the specialist? Some plans limit referrals to specialists. Your dentist may be required to refer you to a limited selection of specialists who have contracted with the plan's third party. You also may be required to get permission from the plan administrator before being referred to a specialist. If you choose a plan with these limitations, make sure qualified specialists are available in your area. Look for a plan with a broad selection of different types of specialists.

If you have children, you may prefer a plan that allows a pediatric dentist to be your child's primary care dentist. Since specialized treatment is generally more costly than routine care, some plans discourage the use of specialists. While many general practitioners are qualified to perform some specialized services, complex procedures often require the skills of a dentist with special training. Discuss the options with your dentist before deciding who is best qualified to deliver treatment.

Can you see the dentist when you need to, and schedule appointment times convenient for you? Dentists participating in closed panel or capitation plans may have select hours to see plan patients. They may schedule appointments for these patients on given days, or at specified hours of the day, restricting your access.

Some dentist's fees for seeing you on weekends or during emergencies are high than those the plan allows. You may be required to pay additional costs yourself. If you select these types of plans, have a clear understanding of your dentist's policies as well as the plan's dentist-to-patient ratio. It's the best way to ensure your access to care is not unduly restricted and that you are not surprised by higher fees the plan does not cover.

Insurance companies do their best to ensure that their policyholders understand their plans and benefits, but it is up to an individual to make sure that they are making informed choices. The differences in the various plans you can choose from are:

The type of third party funding the plan.
Methods of selecting a dentist.
Compensation of the dentist's services to you.
The calculations of benefits and payments.

Understanding these differences will enable you to make an informed decision when selecting a dental plan that is best for you or your family.