What do dental plans normally cover?
There are seven basic areas of dental care that policies cover. With individual policies, often only the first four will be covered in the initial year of a policy with the last two available in later years. Orthodontics is usually a rider for both individual and group policies that can be selected when relevant.
- preventive care, i.e. cleaning, routine office visits;
- restorative care, i.e. fillings and crowns;
- endodontics, i.e. root canals;
- oral surgery - tooth removal and minor surgical procedures such as tissue biopsy and drainage of minor oral infections;
- orthodontics--retainers, braces, etc.
- periodontics - scaling, root planning and management of acute infections or lesions; and
- prosthodontics--dentures and bridges.
Dental benefits overcome consumers’ top concern about getting the care they need—cost. The seven types of procedures are broken into three areas of coverage for payment purposes, i.e. preventive, basic and major.
Most plans cover 100% of preventive care and apply co-payments, either as a dollar amount (DHMOs) or as a percentage (DPPOs and Dental Indemnity/ or Traditional Insurance) to other levels of care. Preventive care usually includes periodic oral evaluations, x-rays and sealants. (NOTE: Sealants may be limited to certain age groups.)
Basic procedures, i.e. office visits, extractions, fillings, root canals, and periodontal treatment for gum disease, are typically covered at a lower percentage amount, for instance 80% when in network or a lower amount like 60% when a dentist is not in the network. In the case of a DHMO, there will be lower dollar co-payments for these procedures rather than percentages. For instance, if a service cost $100, the DHMO co-payment would be stated as $20.
Major procedures, i.e. crowns, bridges, inlays, and dentures are usually covered at the lowest percentage, such as 50% or a higher dollar co-payment in the case of a DHMO. Some carriers now offer coverage for implants under this category of coverage but may have a frequency limitation like one per year. (NOTE: Root canals are also sometimes covered in this category rather than as a Basic procedure, so check your coverage.)
About 54% of dental PPOs, the predominant dental product in the market, have a maximum annual benefit of $1500 or more. While more of those with lower annual maximums hit the maximum, in the past 6 years on average only 5% of enrollees have reached their annual maximum for in-network services. Just under 4% hit the annual maximum for out-of-network services.
This fact keeps employers from offering dental PPOs with higher annual maximums as the additional premium cost may not be affordable. While employers contribute some amount to dental coverage for most employees that are offered benefits, since 2010 the portion of employees paying the full premium for their dental benefits has tripled from 10% to just under 30%.
Deductibles for these products are usually between $50 and $100. Some carriers now offer policies that roll some portion of unused their annual maximum.
NOTE: DHMOs rarely have an annual maximum while most dental indemnity product annual limits parallel DPPO limits.