Picking a dental insurance plan doesn’t have to feel like a game of Eney, Meeney, Miny, Moe.
When open enrollment rolls along and your employer offers you a choice of dental plans, knowing some insurance basics can help you pick the best option for you and your family. Let’s break down all that insurance jargon—and offer up some advice for what to look for—so you can get the most from your benefits.
When is open enrollment?
For most companies, the open enrollment period for group dental plans (aka employer-provided plans) falls in November or early December.
If you’re buying individual or family dental insurance through the marketplace, the deadline for purchasing coverage is the same as for health insurance. This is usually early December. Certain situations, like moving to a new state or a change in employment status, can affect this deadline.
What plan materials should I ask for?
Often you won’t receive that big “Dental Plan Booklet” from an insurance company until after you’re enrolled. This isn’t much help when you’re trying to weigh plan options! We recommend you ask your HR representative for a few key pieces of information, which we’ll call your “Plan Materials:”
- Summary Plan Description (SPD): This document provides an overview of what is provided by the plan, and how the plan works.
- Summary of Benefits and Coverage: This document outlines what your insurance will and won’t cover.
You should also be able to download these plan-specific materials directly from an insurance company’s website.
What to Look for in Your Dental Plan Materials
When considering a new dental plan, knowing what to look for in the materials you’re given will help you make an informed choice. Here are some areas that should really stand out in the Summary Plan Description and Summary of Benefits and Coverage.
In-Network vs Out-of-Network Dentists
Many dental insurance plans will only cover treatment from dentists in their set network. These are known as in-network providers.
Some plans allow you to see dentists outside of their network. These are known as out-of-network providers. However, these plans usually cover a lower percentage of the cost charged by out-of-network dentists than they do for in-network dentists.
Can you see your own dentist?
Make sure any option you consider allows you to see your own dentist. It’s always a good idea to call your dentist’s office and ask if they accept the plans you’re considering. Due to treatment restrictions placed on dentists by insurance companies, many dentists choose not to participate in specific insurance plans.
Coverage Restrictions & Limitations
Most dental plans place restrictions and limitations on coverage. When you read your plan materials, look for the following:
- Does the plan offer basic coverage for preventive care?
- Does the plan cover common dental treatments?
- Does the plan provide coverage for specific treatments you know you’ll need?
- Will you have a deductible?
- Is there an annual maxim the plan will cover?
Skim for any other restrictions that may jump out at you. Make sure they’re reasonable and realistic for you and your family’s needs.
Many policies require a mandatory waiting period. It could be 3, 6, 12, sometimes even 18 months before your full dental coverage takes effect.
Some policies won’t cover any treatment until the waiting period ends. In other policies, this only applies to more extensive procedures (like crowns and bridges), but not to preventative or routine care (like cleanings and check ups).
Consider waiting periods when evaluating your options, but don’t let them prevent you from getting the care you need.
UCR Fee Schedules
Insurance companies put caps on the amount they will pay for any procedure. Most dental plans use a USUAL, CUSTOMARY, AND REASONABLE” (UCR) FEE SCHEDULE to determine how much of your care will be covered.
A UCR plan will pay either part of your dentist’s fees, or the insurance company’s “customary” fee limit, whichever is less. This limit is set by the company, not your dentist.
If a plan’s “customary” fee limits are unrealistically low, you’ll end up paying more. If a fee schedule is available, take a quick look to see if the allowable amount for your regular treatments look suspiciously low.
80/20 Dental Coinsurance
Under this type of coverage, the dental insurance company pays 80% of the fee for a dental service. The patient is responsible for paying the remaining 20%.
The 80% the plan pays only applies to the “fee” for service as determined by the insurance company, not necessarily 80% of the actual fee charged by the dentist for a procedure.
If the fee is more than the allowable amount set by the insurance company, you’ll be responsible for paying the balance.
Still have questions? Talk to your MDA dentist!
If you’re faced with several options and left guessing between plans, talk to your MDA dentist. They can go over what specific types of treatment you and your family are likely to need on a yearly basis. At the end of the day, only you and your dentist, not an insurance plan, can decide what’s best for you and your family’s specific oral health needs.