Dental insurance works in much the same way that medical insurance works. For a specific monthly rate (or “premium”), you are entitled to certain dental benefits, usually including regular checkups, cleanings, x-rays, and certain services required to promote general dental health. Some plans will provide broader coverage than others and some will require a greater financial contribution on your part when services are rendered. Some plans may also provide coverage for certain types of oral surgery, dental implants, or orthodontia.
Dental health insurance plans vary widely. You should know how your plan is designed, since this can significantly affect the plan’s coverage and out-of-pocket expenses.
Although the individual features of plans may differ, the most common designs can be grouped into the following categories:
- Direct Reimbursement programs reimburse patients a predetermined percentage of the total dollar amount spent on dental, regardless of treatment category. This method typically does not exclude coverage based on the type of treatment needed, allows patients to go to the dentist of their choice, and provides incentive for the patient to work with the dentist toward healthy and economically sound solutions.
- “Usual, Customary, and Reasonable” (UCR) programs usually allow patients to go to the dentist of their choice. These plans pay a set percentage of the dentist’s fee or the plan administrator’s “reasonable” or “customary” fee limit, whichever is less. These limits are the result of a contract between the plan purchaser and the third-party payer. Although these limits are called “customary,” they may or may not accurately reflect the fees that area dentists charge. There is wide fluctuation and lack of government regulation on how a plan determines the “customary” fee level.
- Table or Schedule of Allowance programs determine a list of covered with an assigned dollar amount. That dollar amount represents just how much the plan will pay for those services that are covered, regardless of the fee charged by the dentist. The difference between the allowed charge and the dentist’s fee is billed to the patient.
- Capitation programs pay contracted dentists a fixed amount (usually on a monthly basis) per enrolled family or patient. In return, the dentists agree to provide specific types of treatment to the patients at no charge (for some treatments there may be a patient co-payment). The capitation premium that is paid may differ greatly from the amount the plan provides for the patient’s actual dental care.