Does it feel like you need a college degree in mathematics and logic to figure out your portion of your dental bill, whose office you can go to, or what procedures are covered by your policy? 

If you’ve answered yes, you are not alone.  We receive 100’s of questions per week relating to these issues and more.  Our knowledgeable staff can help you understand & maximize use of your dental insurance benefits.  It’s important to understand your policy, and the choices your employer may be giving you so that you can make the best decision possible in behalf of your dental needs.  Following is a guide to the differences in the major groups of dental insurance policies and benefits commonly offered to employees.

There are basically 5 groups of policies available to us all.  Most dental insurance providers offer a choice of policy matching each group. As is true with most things in life, each policy comes with a different price tag to the purchaser of the policy (usually your employer).  The greater the premium, the greater the benefits to the members.  The insurance carriers may refer to their policies by various names…for ease of consistency we’ve identified them under commonly used descriptors: 

Traditional Dental Insurance:  This type of policy allows you to go to any dentist in the country (You do not have to pick from a list of dentists provided in a book from the insurance company).  Most dental offices now offer to submit your insurance claim for you.  For the few who don’t, you can pay for your appointment in full yourself, then submit the receipt with a claim form to receive due compensation from the insurance company.   

Most dental insurance carriers stipulate an initial deductible to be paid by the member. (Commonly $50.00).  Oftentimes, the deductible is waived for preventative care (cleanings, fluoride, exams and x-rays).  The ‘deductible’ applies the first time the member uses his/her benefits for ‘restorative or operative’ treatment (fillings, crowns, root canals, etc).  This means the member would need to pay the first $50.00 of that treatment.

Most policies are structured to cover a percentage of the treatment being done, expecting the member to cover the remaining percentage.  Insurance companies have grouped different types of procedures into 3 commonly recognized benefit levels: Preventative care (cleanings, fluoride, exams, x-rays and sealants); Basic restorative care (fillings, simple extractions, children’s pulpotomies [root canals on baby teeth], children’s stainless steel crowns); and Major restorative care (adult root canals, adult crowns, bridges, complicated extractions).  As an example of their percentage breakdown of benefits, they may cover ‘preventative’ procedures at 100% (no cost to the member), ‘restorative’ procedures at 80% of the proposed fee (leaving 20% to be covered by the member) and ‘major’ procedures at 50% of the proposed fee (leaving the other 50% to be covered by the member).  This is the most costly policy offered but offers the member the greatest extent of benefits.

 PPO Dental Insurance: This type of policy is similar to the traditional dental insurance in structure but adds a choice to the policy holder.  The member has the choice of using a contracted, ‘in-network’ provider or using an ‘out of network’ provider.  The difference to the member is usually about a 10% difference in dental coverage benefits (10% less when going to an out of network provider).  Most dental specialists like orthodontists, pediatric dentists, oral surgeons, etc do not contract as ‘in-network’ providers so realizing that you can still see the specialists and utilize 90% of your potential insurance benefits is a great asset.  A lot of larger employers in and around Stapleton, like University of Colorado, offer PPO plans as one of the choices to their employees.  This is a great choice for all of your family’s dental needs.

EPO Insurance:  These plans mandate that the member use a dental provider on the list only.  The goal of these policies is to provide basic dental care to the members. Because of this, these policies usually don’t provide provisions for specialists as mentioned above.   

These plans are commonly structured differently from a PPO plan in that the member pays a specifically identified co-pay for most individual procedures according to a fee schedule negotiated by your employer.  At times, these “co-pay” amounts may be greater than the 20% coinsurance (for example, for restorative treatment) expected under a PPO plan.  It is important to understand this because although the monthly premium may be lower (thus initially making these plans look more attractive to choose), the member may commonly pay more out of pocket upon use of the benefits.  Since children in general are at greater risk of tooth decay than adults, we usually recommend to family’s with young children to “choice up” to the PPO plan whenever possible.  We have found most family’s with children come out financially ahead over the course of a year by doing so.  In addition, since this type of policy usually does not provide provisions for specialists, family’s on this plan commonly do not have good access to pediatric dentists (particularly important if you have children aged newborn to 10 years old).  For more information of the differences and importance of using a pediatric dentist, please click here.

In general, this is one of the least expensive types of policies to acquire so one must weigh the benefits to the cost.   

Discount Plan: This newer concept for dental coverage simply provides the member with a percentage discount across the board for all dental procedures (for example 25% off of all fees).  The member is responsible for paying the remaining 75% of their dental bill.  There is no deductible and no claims are filed with an insurance company.  The dental office commits to providing the discounted fee.  This is often a great solution for ‘self-employed’ families who do not have access to group dental insurance.   We partner with 2 discount plans: Ameriplan and NHCD.

Fee Schedule:   Unlike traditional insurances which pay a percentage of the dentist’s fees, a plan that pays on a Fee Schedule pays a nominal, set dollar amount for each procedure code.  Your insurance company will give you a copy of this schedule upon request.

Oftentimes, employers allow their employees to pick the policy they wish to have, requiring the employee to pay the difference in the premiums.  Weighing your options becomes an important consideration.  Feel free to call our office for a personal insurance consult to help you pick the policy right for you.