How Dental Plans Work

Dental benefits should be just that—a benefit to you and your family. While you don’t need dental insurance to receive care, having dental coverage can help lower the cost of certain treatments.

MDA dentists know it’s important for you to get the most from your dental plan. Below, we explain how dental plans work and include tips to help you maximize your benefits.

Evaluating a Dental Plan

When you’re considering a dental plan, first thing’s first, make sure you can still visit your own dentist. Why? Because, a lot of dental plans don’t take into account your doctor/patient relationship. You might be limited to using one of the dentists in their network. That’s why it’s so important to choose a plan that lets you stick with your own dentist.

What questions should I ask when considering a dental plan?

So much varies from plan to plan. Here are a few key questions to ask when evaluating a plan:

  • Can I see any dentist I choose?
  • Can I see a specialist any time my dentist or I believe it’s necessary?
  • Can I change my dentist at any time?
  • Am I directly involved, along with my dentist, in choosing the best course of treatment to fit my specific needs?

The answers to all the above questions should be “yes.” If the answers are mostly “no,” you’re probably looking at a restricted dental plan. In that case, your dental health isn’t the insurer’s top priority. If the option is available, you may want to re-evaluate and select an option that will let you answer “yes” to those questions.

Common Types of Dental Plans

Most dental plans are restricted. That means they limit their members in two ways—in the number of dentists they can choose from and the amount of covered care they may receive.

Many restricted dental plans base the amount of treatment they will cover to a set amount per person, rather than a set amount per procedure.

When deciding how much care should be provided for each patient, these insurance plans base their estimates on what the “average patient” is likely to need. The problem? There’s no such thing as an average patient.

Restricted plans limit your dentist, too. These plans don’t always cover treatments that are critical to your overall health. Because of this, many dentists choose not to participate in restricted plans.

What is a DHMO Insurance Plan?

The most common type of restricted dental plan is a Dental Health Management Organization Plan (aka a DHMO Plan or an HMO Dental Plan).

DHMOs limit patient coverage to dentists within a set network. They will not cover or reimburse for treatment by dentists outside of their network.

What is a DPPO Insurance Plan?

A Dental Prefered Provider Organization Plan (aka a DPPO or a Dental PPO) offers more flexible coverage options. DPPOs provide patients with access to dentists within a set network and allow patients to see dentists outside of their network.

DPPOs prefer it when you go to an in-network dentist. They will cover a higher percentage of the fees charged by dentists within their network than they will for dentists outside of it. You may pay a bit more to see a dentist out-of-network, but your insurance will still provide coverage.

What is a dental insurance coverage waiting period?

Not all plans have waiting periods. However, it’s common for dental insurance companies to require you to be a paying member for a set time (often 3, 6, or 12 months) before your full coverage takes effect.

Insurance companies claim waiting periods prevent people from joining a plan when they need dental work, only to cancel as soon as they get their smiles fixed.

How Dental Fees & Benefit Amounts Are Set

When you sign up for dental benefits through work, you join a “group policy.” Your employer pays that company a set premium, which the insurance company in turn uses to pay for your care.

The specifics of the “group policy” depend on your employer’s contract with the insurance company. Generally, the higher the premium you and your employer pay, the less you’ll be expected to pay out of your own pocket.

How are my dentist’s fees determined?

Your dentist charges you for the actual treatment performed and the time it took to complete, as well as a portion of their office overhead.

Your dentist’s overhead includes the cost of having quality staff, state-of-the-art equipment, modern dental materials, current infection control procedures, and continuing education to ensure that your dental team is up-to-date on the latest techniques.

What is a UCR Fee Schedule?

Many insurance plans use a “Usual, Customary, and Reasonable” Fee Schedule, also known as a UCR, to decide what portion of your dental treatment they will cover.

  • A “Usual” Fee is the fee that an insurance company believes individual dentists usually charge for a specific procedure. This fee varies from office to office.
  • A “Customary” Fee is the highest fee level a dental plan administrator decides they will pay for a specific dental procedure.
  • A “Reasonable” Fee is the amount a dentist charges if a procedure has special circumstances that justify a higher fee.

A UCR plan will pay either a set percentage of your dentist’s fees, or the policy’s “reasonable” or “customary” fee limit, whichever is less.

These limits are set by your or your employer’s contract with the insurance company. They may or may not reflect the actual costs of dental care in your area. If a plan’s “customary” fee limits are unrealistically low, you will end up paying a larger portion of the treatment costs.

Why is there such a big difference between the amounts dental insurance companies will cover?

There are no state-wide or nation-wide standards for determining fees insurance companies will pay. Even if two insurance plans are housed in the same building and owned by the same company, the plans’ administrators might set different UCR rates for the same procedure.

Responsible Dentistry & Your Patient Rights

The Michigan Dental Association and its member dentists are committed to the practice of responsible dentistry. When they provide treatment, they assess your specific situation and design a treatment plan based on what’s best for your dental health. Always.

Your MDA dentist may choose what is medically best over what your insurance company thinks is most cost-effective. Treating you based on the needs and problems of an insurance company’s undefined “average” patient compromises your dentist’s ability to provide you with the best care.

Your Dental Patient Rights

The MDA and it’s member dentists believe in upholding your patient rights. Your insurance company should too. These include:

  • The right to choose your own dentist.
  • The right to change dentists.
  • The right to consult a dental specialist.
  • The right to be treated as an individual patient.
  • The right to say “no” to a procedure or treatment option.

If you lack one or more of these very important dental freedoms, your oral health will likely be compromised.

What should I do if I get a denial letter from my insurance company?

If you get a letter from your insurance company stating they are denying payment because your dentist’s fees are above your plan’s UCR rate, talk to your dentist. Your insurance company might have out-of-date information, or might not have considered local factors when they set their fee schedule.

If after talking to your dentist and your insurance company you are still not satisfied, talk to your employer, HR representative, or union. Let them know that the benefits they have purchased do not meet their employees’ needs.

What should I do if I need dental treatment that isn’t covered?

Only you and your dentist can decide what treatment is right for your individual dental needs. MDA dentists never recommend putting off necessary dental work due to insurance coverage restrictions or waiting periods. This can be dangerous to your oral health and may be even more costly in the long run.

You always have options. Talk to the billing staff or office manager at your dentist’s office about your payment choices. Most practices will allow you to set up a payment plan so you can pay for a non-covered procedure over time and in installments. Others may provide generous discounts for payments made upfront at the time of service.

Talk to Your MDA Dentist

For more reading on dental insurance, see our other articles on the MDA Smile Connection Blog. We think you’ll love these:

Dental Insurance Myths

How Can I Get the Most for My Money When It Comes to Dental Care