Dental Insurance Explained
Wednesday, January 13, 2010
Dental insurance can be confusing to everyone. Let's break it down into the basic types of dental insurance.
Traditional Plan:
- Can go to any dentist or dental specialist.
- Has a fixed yearly deductible.
- Has a fixed maximum dollar amount the insurance will pay yearly. Any amount of work beyond this maximum is the responsibility of the patient.
- While the insurance has a yearly maximum, any given procedure is paid at a percentage of the actual charge.
- Dentist charges full price for dental services.
- Must go to only an "in-network" dentist or dental specialist. Usually a large number of dentists are eligible in network providers.
- Has a fixed yearly deductible.
- Has a fixed maximum dollar amount the insurance will pay yearly. Any amount of work beyond this maximum is the responsibility of the patient.
- While the insurance has a yearly maximum, any given procedure is paid at a percentage of the actual charge.
- Dentist charges contracted prices for dental services covered by the insurance plan, and charges full price for dental services not covered under the plan.
PPO Plan - Out of Network Dentist:
- Can go to any dentist or dental specialist.
- Has a fixed yearly deductible.
- Has a fixed maximum dollar amount the insurance will pay yearly. Any amount of work beyond this maximum is the responsibility of the patient.
- While the insurance has a yearly maximum, any given procedure is paid at a percentage of the actual charge. This percentage is often, though not always, slightly lower than that paid to an in-network dentist.
- Dentist charges full price for dental services.
DMO or HMO:
- Must go to the assigned "in-network" dentist. Only one dental provider is assigned per patient.
- To see a specialist, a patient must first obtain a referral from the assigned in-network primary care dentist.
- No deductible.
- Has no fixed maximum dollar amount the insurance will pay yearly because the insurance does not pay per procedure performed. The patient pays the entire copayment for every dental procedure that is completed. The only payments made to the dentist by the HMO plan are based on a predetermined, fixed, monthly, payment that is based only on the number of patients assigned to the practice by the HMO, and is not in any way related to the actual procedures performed on those patients.
- Dentist charges contracted prices (equivalent to the patient copayment) for dental services covered by the insurance plan, and charges full price for dental services not covered under the plan.
