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Dental Insurance 101

Getting The Most Bang For Your Dental Buck

By Tom Limoli Jr.


Different Strokes…

Direct Reimbursement. Some dental plans are self-funded by your company. That means the company pays the employees' dental bills from company funds as they come due. This tends to work better for smaller companies. It is not insurance company money that is paying the claims. An insurance company is only involved as an administrator — a manager who writes checks, essentially. The insurance company will write checks off the employer's account to pay dentists or reimburse employees, depending on how the particular plan is structured. Every time the insurance company writes a check, it writes itself one as well for a small percentage of the dental bill — ranging from half a cent to three-and-a-half cents for every dollar paid out in benefits. This is how the insurance company makes money on the deal — by administering the plan, not by collecting premiums that will exceed what they pay out.

Then there are Managed Care dental plans that reduce a patient's out-of-pocket expenditures, but consumer choice is more restricted. These include Dental Health Maintenance Organizations (DHMOs) and Preferred Provider Organizations (PPOs). These plans work better for large dental group providers, who have a lower overhead and can provide treatment more cheaply, than for a “solo” practicing dentist. That doesn't mean that the care is not of the same standard — all dentists should practice to the standard of care recognized by the state in which the dentist practices.

Managed care plans require individuals to choose a dentist from a list of participating providers who have agreed to accept a flat monthly fee (DHMOs) or to discount their fees deeply (PPOs) in exchange for the patient referrals. To reap the benefit of this, you might have to leave a dentist you've been going to for years. For many patients, this is a deal-breaker.

Far From Ideal

At the end of the day you are in charge of your own healthcare — not your employer, your insurance company, or even your dentist.

It's a system that's far from ideal, but there is one bright spot: all parties — your employers, the insurance company, your dentist, and you — all favor prevention. So if you have a plan that will pay for a twice (or even once) a year exam, use it to help stay healthy and avoid costlier treatments down the road. Here are some other things you can do to get the most out of whatever coverage you have:

  • Make sure you understand your plan fully, particularly its restrictions. If you have questions, talk to your company's human resources person or call the insurance company's toll-free number.
  • Let your dentist's office help you get the most out of your coverage. While dental insurance can be confusing to you, this is a world (complete with its own language) in which your dentist's staff functions every day, and most are willing to help you figure it out. They might even be able to help you get an allowance towards the cost of a procedure that's not explicitly covered (for example, put the money you would have gotten for a bridge towards an implant instead). But remember, it's your insurance, and while your dental office can help you interpret the language, you are your best advocate in getting the benefits to which you are entitled, and that are specified in your policy.
  • Work out with your dentist how to pay for what's not covered. Many offer options to spread payments over time. Neglecting care will cost you more money in the long run. A lot of money. You may be able to make a separate financial arrangement with your dentist for the care you need, and have your insurance company reimburse you directly to the extent that the procedures you need are covered. This may work out better for you and your dentist.

Finally, keep in mind that at the end of the day you are in charge of your own healthcare — not your employer, your insurance company, or even your dentist. Don't let a lack of coverage keep you out of the dentist's chair for inexpensive routine maintenance. If you don't have insurance at all, it's even more important to make that minimal investment in your health and the health of your children by going twice yearly. That's really the best dental insurance anyone can buy.