Hooray! Your employee benefits package includes dental coverage. Now you can relax and quit thinking about the cost of treatment. Well, not exactly. No plan covers everything. And dental benefits usually decrease as your treatment needs increase. Do you know what your dental coverage includes? If you're like most people, you're probably not sure. Here are some pointers to help you sort through the confusion as you read through your plan description.
1. Dental plans focus on preventive care.
Most dental benefit plans focus on coverage for "preventive" care, because prevention is a proven way to head off most serious dental problems. That's why oral exams, cleanings, X-rays, sealants and fluoride treatments are the most common benefits in dental plans. And they're usually covered at a high level. While coverage for fillings, extractions and other types of "restorative" care is often included, dental plans vary widely in what and how much restorative treatment is covered.
2. Employer-sponsored dental coverage.
Almost all dental plans are created by contract between the plan sponsor (usually an employer or union) and an insurance company or managed care organization. How much is covered depends on the amount of premiums paid. It's important to remember that there are hundreds of different dental plans and your dentist is not involved in deciding any of the benefits or coverage levels. That's why you should always talk to your employer (plan sponsor) about problems you encounter with your plan.
Three different types of dental plans are typically purchased or adopted: traditional insurance, managed care or direct reimbursement.
Traditional Insurance - Your employer purchases a fixed amount of coverage through an insurance company that provides dental benefits. You choose the dentist you prefer, and you or your dentist are reimbursed for a defined set of procedures at coverage levels set by the insurance company.
Managed Care - Also known as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), these organizations contract with certain dentists and you must see one of the dentists in the plan in order to receive full benefits. As with traditional insurance, your employer contracts with the HMO or PPO for specific dental procedures at specific coverage levels defined by the plan.
Direct Reimbursement - Instead of contracting with an insurer or managed care organization, your employer finances its own benefit plan. Typically, you have a specified dollar amount of coverage that you can generally apply to any dental procedure you need (traditional and managed care plans spell out what procedures are eligible for coverage). .
3. All dental plans are not created equal.
When you're deciding whether or not to participate in a dental plan, here are some important considerations to weigh:
Freedom to Choose Your Own Dentist. Some plans let you see any dentist you want. Other plans restrict you to a specific group of dentists. Does the plan let you keep your current dentist or will you need to change dentists? Does the plan's provider network include dental specialists?
Benefits and Coverage. Does the plan only cover certain dental procedures or are you free to apply the dollar amount of your coverage to any care you may need? What are the plan's limitations and exclusions? Does the plan cover you and your family members or just you?
Cost to You. Do you have to pay a portion of the premium through payroll deduction to participate in your dental plan? If so, how many dental services do you use in a typical year? Do the benefits you receive exceed your payroll deduction? Or would it cost you less to opt out of the plan and pay for your care yourself as you need it?
Ease of Use. How easy is it to understand and use the plan's benefits? What procedures and rules do you have to follow to take advantage of your benefits? Do you have to get advance authorization from the insurance company for some types of treatment? Do you have to file claim forms to get coverage, or does the plan or your employer handle the paperwork for you?
Knowing these basics will help you ask your employer or plan sponsor the right questions and decide how important each consideration is to you and your family.
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