To start there are two basic types of plans: PPO’s and DHMO’s. Here is a general summary of each.
A PPO allows you to go to any dentist you want. If you use a network dentist, your bill will be less than if you use a dentist that is not in the network. Often plans require the dentist to submit a treatment plan prior to performing any major services so you should have the estimated cost upfront. You can request this from your dentist even if the insurance company does not require it.
Services are usually grouped into 3 levels of coverage: preventive, basic and major.
- Preventive is exams, cleaning and x-rays.
- Basic is fillings and simple extractions
- Major is everything else – gum disease, crowns, root canals, etc.
Some policies have orthodontic coverage too (braces)
Usually there is a minimal annual deductible that you pay for services other than preventive. Then the amount of the bill you pay is based on the coverage level. There is a annual maximum amount that the insurance company will pay for services.
A typical plan is 100/80/50, $50 ded waived on preventive, $1000 max. This means that the insurance company pays 100% of preventive services with no deductible, 80% of basic and 50% of major services after you pay a $50 annual deductible. The total amount the insurance company will pay annually is $1000.
NOTE: there is usually a waiting period for basic and major services before the insurance company will cover those services. Preventive services are covered right away.
A DHMO is quite different. You must use a network dentist, the cost for each service is a fixed price and there are no waiting periods or annual limits on services. Also, the monthly premium you pay is usually much less than a PPO.
What makes a DHMO attractive is not having any waiting periods or annual limit. If you need five fillings, two crowns and a root canal, you can get those done the first day you are covered. You just pay the fixed cost for each service. The costs are listed in your policy so you know exactly how much everything will cost ahead of time.
The drawbacks are having to use a network dentist and getting the first appointment. Because of the way dentists are paid in a DHMO, they often limit how many patients they see in a given period of time. However, once you are on a regular schedule of getting your cleanings done every six months, this is not usually a problem.
As always know what your benefits are BEFORE you go to the dentist. Read your benefits book and make sure you go to a network dentist if it is required and if not find one to save the most money. If you do not understand something, call customer service. They are there to help.