Did you know that many Americans do not have access to dental care?
Yes, according to recent studies, 60% of Americans have not visited a dentist within the last year because of the high cost.
However, with dental insurance, this inaccessibility gap closes, providing much-needed relief and giving more people access to both essential and preventive dental treatments.
This article will break down the structure of dental insurance in the US, highlighting the types, their coverages, statistics, and some trends.
So, let’s get right to it, shall we?
Why Is Dental Insurance Important?
According to a study by the National Association of Dental Plans (NADP), over 80% of the American population have dental coverage through individual plans, group plans, or publicly funded benefits.
However, despite the high number of Americans with dental insurance, over 60 million adults in the US don’t have any dental coverage.
Besides, you cannot overstate the Importance of dental insurance, as most dental treatments without insurance are extremely expensive; for example, the average cost for a root canal without insurance can be over $1,000.
Another example is the average cost of wisdom tooth removal without insurance. This can reach up to $500 per tooth.
Furthermore, unlike average health insurance, dental insurance rarely covers 100% of the cost of major procedures.
So, if you wanted to get a root canal, your insurance wouldn't pay the entire cost, and neither would you.
Understanding Dental Insurance: Why Are Different Levels Of Insurance?
The different levels of dental insurance exist to provide flexibility and cater to the diverse needs, budgets, and preferences of individuals and families.
Dental care is not a one-size-fits-all service, and people's dental needs vary significantly based on factors such as age, income, location, and oral health priorities.
Here's a breakdown of why dental insurance plans are structured at varying levels:
What Are The Different Types of Dental Insurance Plans?
It is important to understand the several types of insurance plans available, whether you are getting one on your own or through your employer.
Some of these plans have limited maximum charges, while others have fixed fees for different services. Below is a comprehensive list of the types of dental insurance plans in the US.
Preferred Provider Organizations (PPO)
A PPO plan is a regular insurance plan that has a large dentist network under contract and offers different services for fixed fees.
Most dental insurance companies that offer these plans share a part of the reduced fees, allowing members to pay less out of pocket.
Using dentists in their network will help you reduce your costs as they must accept the maximum allowable fee, but you can also use other dentists, although the fees may be higher.
Not all PPO plans are the same, as different insurance companies offer varying benefits and limitations with their PPO plans.
Additionally, the NADP reports that PPO plans remain dominant amongst other commercial dental plans, with 86%.
Health Maintenance Organizations (HMO) /Capitation Plans
Unlike PPO plans, HMO plans allow you only to use the dentists in their network, and they focus more on preventive care.
The dentists in the network must offer their contracted services, like cleanings, x-rays, and regular oral evaluations, at no cost or reduced cost to the patients.
Also, because the insurance providers prepay the dentists, neither the dentists nor patients get money back for services, ensuring that you receive treatment at a contracted dentist to receive insurance.
You do not get insurance if you use a dental service outside the network, except in emergencies. HMO plans usually cost less than other dental insurance plans because of their restrictions and low monthly premiums.
Dental Discount or Savings Plans
Dental discount plans differ from traditional dental insurance plans as there is no coinsurance or claim paperwork to fill out.
In this plan, members choose from a group of dentists who agree to charge discounted fees for their services.
Members usually pay annually in exchange for these discounts, which are typically lower than most other dental insurance plans. Besides, nowadays, more employers are purchasing these types of plans for their employees.
Point of Service (POS)
A Point-of-Service plan is managed health insurance that provides coverage for dentists in and outside its network, but the coverage amount differs. Just like HMOs, members must choose an in-network dentist, and if they need to visit a dental specialist, they need a referral from the contracted dentist.
Plus, members need to pay a certain percentage for any service provided by the dentist, and the plan will cover the rest.
Dental Indemnity Plans
These plans are mostly referred to as traditional insurance plans, as they have a deductible that you need to pay out of pocket before the insurance plan takes over and pays the rest.
Unlike other plans, there is no network of dentists to choose from, so you can choose any dentist you want. With this plan, you need to pay your dentist at the time of service and then submit a claim for reimbursement from your insurance company.
However, most dentists file the claim directly and bill you for only the deductible.
Exclusive Provider Organizations (EPO)
EPO plans limit members to only the dentists in their network if they want the plan to reimburse them.
If you use a dentist who is not in the network, you will be fully responsible for all fees charged. This plan is good for members looking for dental preventive care, but it is very restrictive.
Public Funded Dental Coverage (Medicaid, Medicare, ACA)
Public-sponsored programs like Medicaid, Medicare, and CHIP help to close the gap that exists in accessing dental care.
Most states cover dental care for children through Medicaid and the Children’s Health Insurance Program (CHIP). However, most states independently decide whether to provide dental benefits for adults through Medicaid.
Another way to obtain dental benefits is with Medicare Advantage plans because traditional Medicare does not include dental treatments.
The Affordable Health Care Act (ACA) also allows you to get dental benefits as part of your health plan or through a different dental plan.
Here is a Summary Table of The Dental Insurance Level Comparisons:
What Dental Insurance Plans Cover
Most dental plans cover preventive care, restorative care, endodontics, and oral surgery, but the percentages differ. Some dental insurance plans cover 100% of preventive care, which includes oral evaluations, sealants, and X-rays.
Others, like HMO plans, apply copayments, while PPOs and dental indemnity pay a certain percentage on basic procedures like extractions, root canals, fillings, and gum disease treatment. Besides, major procedures, like dentures, bridges, and crowns, are covered at a lesser percentage.
You need to read the fine print of the insurance plans to see how much they cover for various dental treatments, enabling you to choose the best one for your needs.
What Is the Most Convenient Level of Dental Insurance?
The most convenient level of dental insurance depends on your personal dental care needs, budget, and priorities.
For Most People: A PPO plan strikes the right balance between flexibility, coverage, and cost, making it the most convenient choice for individuals and families with moderate dental needs.
For Budget-Conscious Individuals: An HMO plan or Dental Discount Plan provides affordable access to preventive care.
For Maximum Freedom: A Dental Indemnity Plan offers flexibility, but it’s more expensive.
For Low-Income Individuals: Medicaid/CHIP is the most convenient option if eligible.
Ultimately, the "most convenient" plan is one that aligns with your specific needs, covers the treatments you’re likely to require, and fits your budget.
How to Pick the Right Dental Insurance Level?
Choosing the right dental insurance level depends on your dental care needs, financial situation, and preferences for coverage. Here’s a step-by-step guide to help you select the best plan:
1. Assess Your Dental Needs
Preventive Care: If you mostly need cleanings, checkups, and X-rays, a basic or low-cost plan like an HMO or PPO might work for you.
Major Procedures: If you anticipate needing more expensive treatments like root canals, crowns, or orthodontics, consider a comprehensive plan like a PPO or Dental Indemnity Plan.
Family Coverage: If you have children, look for plans that include kids' orthodontic care or benefits like sealants and fluoride treatments.
2. Set Your Budget
Premiums: Decide how much you can afford to pay monthly for the plan.
Out-of-Pocket Costs: Review deductibles, copays, and coinsurance to estimate what you’ll pay for treatments.
Annual Maximum: Many plans have a cap on the amount they’ll cover per year (e.g., $1,000–$2,000). If you expect high dental expenses, choose a plan with a higher annual maximum.
3. Check the Provider Network
Preferred Dentist: Do you have a specific dentist you want to keep seeing?
If yes, make sure they’re in-network for plans like PPOs, HMOs, or EPOs.
If not, consider a plan like a Dental Indemnity Plan that lets you visit any dentist.
Network Size: PPOs often have large networks, while HMOs and EPOs have smaller, more restrictive networks.
If you have any more queries about the different levels you can take to treat your teeth, call our answering service anytime at 720-580-1117.
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