Question

What types of services are covered by dental insurance contracts?

Answer 1

INTRODUCTION

Dental insurance is a form of health insurance 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: Indemnity, Preferred Provide Network (PPO), and Dental Health Managed Organizations (DHMO).

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 an area. The fee schedule is commonly used as the transactional instrument between the insurance company, dentist, and the consumer.

What types of services are covered by dental insurance contracts?

1) Preferred Provider Organizations (PPO)

A PPO plan is regular insurance combined with a network of dentists under contract to the insurance company to deliver specified services for set fees and according to the provisions of the contract.

Contracted dentists must usually accept the maximum allowable fee as dictated by the plan, but non-contracted dentists may have fees either higher or lower than the plan allowance.

The following are the services covered:

100% coverage for preventive and diagnostic services( $50 annual deductible applies to all services except preventive and orthodontic ). This includes routine checkups and cleanings. A typical dental insurance policy covers two checkups a year.

80% coverage for basic restorative services treatment procedures such as fillings and root canals.

50% coverage for major restorative services crowns, bridges, and other major treatment procedures.

50% coverage for orthodontics subject to separate lifetime maximum of $1,000

$1,000 annual maximum for all services except orthodontics .

2) Dental Health Maintenance Organizations (DHMO)/Capitation Plans

A dental health maintenance organization is a common example of a capitation plan. Under a capitation plan, contracted dentists are “pre-paid” a certain amount each month for each patient that has been designated or assigned to that dentist. Dentists must then provide certain contracted services at no-cost or reduced cost to those patients. The plan usually does not reimburse the dentist or patient for individual services and therefore patients must generally receive treatment at a contracted office in order to receive a benefit.

The following are the services covered:

Preventive and diagnostic services require no co-payment by the patient

Other covered services require the agreed upon patient co-payment

With a capitated plan there are no dental claim forms to submit .

3) Indemnity Plans

An indemnity dental plan is called “traditional” insurance. In this type of plan an insurance company pays claims based on the procedures performed, usually as a percentage of the charges.   

Generally an indemnity plan allows patients to choose their own dentists, but it may also be paired with a PPO. Most plans have a maximum allowance for each procedure referred to as “UCR” or “usual, customary and reasonable” fees.

The following are the services covered:

100% coverage for preventive and diagnostic services

$50 annual deductible applies to all services except preventive and orthodontic

80% coverage for basic restorative services

50% coverage for major restorative services

50% coverage for orthodontics subject to separate lifetime maximum of $1,000

$1,000 annual maximum for all services except orthodontics

4)Direct Reimbursement (DR)

Direct Reimbursement is a self-funded plan that allows patients to go to the dentist of their choice. Depending on the plan, the patient pays the dentist directly and then submits a paid receipt or proof of treatment.

The administrator then reimburses the employee a percentage of the dental care costs.   

The following are the services covered:

Plan A: 100% of the first $200 of dental exdental, 80% of the next $250 of dental expenses, 50% of the next $2,200 for an annual maximum of $1,500

Plan B : 100% of the first $100 of dental expenses, 80% of the next $1,750 for an annual maximum of $1,500 .

5 )Point of Service Plans

Point of service options are arrangements in which patients with a managed care dental plan have the option of seeking treatment from an “out-of-network” provider.   

The reimbursement to the patient is usually based on a low table of allowances; with significantly reduced benefits than if the patient had selected an “in network” provider.

6) Discount or Referral Plans

In Discount plans, the company selling the plan contracts with a network of dentists. Contracted dentists agree to discount their dental fees. Patients pay all the costs of treatment at the contracted rate determined by the plan and there are no dental claim forms to file.   

7) Exclusive Provider Organizations (EPO)

Exclusive provider organization plans require that subscribers use only participating dentists if they want to be reimbursed by the plan. These closed panel groups limit the subscriber’s choice of dentists and also can severely limit access to care.

8)Table or Schedule of Allowances Plans

These types of plans are indemnity plans that pay a set dollar amount for each procedure, irrespective of the actual charges. The patient is responsible for the difference between the carrier’s payment and the charged fee.