How Does Dental Insurance Work?

If you are needing some form of dental treatment, and have dental insurance, you’re probably wondering exactly how it works. Insurance companies, unfortunately, make things as complicated as possible to profit from yourself and your dental team. In this article we will break down what dental insurance is, the different forms of insurance, and how it can benefit you.

What is the difference between a PPO and DHMO dental insurance?

These are the two main kinds of dental insurances that people have. PPO stands for a Preferred Provider Organization, while a DHMO stands for Dental Health Maintenance Organization Plan. Let’s see exactly how they work:

• PPO Dental Insurance: These types of plans can come from any carrier whether it be Cigna, Delta, United Healthcare, or even smaller insurance companies that you may not have heard of. These plans normally carry a yearly maximum that typically ranges between $1,000-$2,500 (although some plans can be less or more). A yearly maximum is that amount of money that the carrier will spend on your dental care in one calendar year. Most plans start January 1st, but there are other plans that can start at any time during the year. PPO plans also cover dental treatment at a percentage meaning they normally do not pay for all of your treatment. For example, a particular plan may cover 50% of a dental crown that you may need, or 80% of a tooth filling. The percentage that is not covered by the plan will have to be paid from your own pocket. Some patients may have two PPO plans under their name (the other is usually under a spouse), where the plans are known as primary and secondary, respectively. The primary plan is usually what your employer provides you with while the secondary will normally be under the plan that is provided to your spouse. Your children may be under both plans as well. If this is the case, their primary insurance will be under what is known as the ‘birthday rule.’ Whichever parents birthday falls earlier in the calendar year is considered to be the plan that is the primary for the children.
• DHMO Dental Insurance: These plans are also known as discount plans, and they differ from PPO plans. These plans normally do NOT carry a yearly maximum. A contract is negotiated with the dentist to provide services based on prices that the dental insurance companies see fit. These plans do not carry yearly maximums, and they do not pay the dentist a percentage of what the treatment costs. All these plans do is reduce the costs that you need to spend to get the dental treatment that you need. Most of these plans offer free basic dental cleanings twice a year, and substantially reduce the costs of other forms of dental treatment. Many dentists do not accept these plans because of the poor fees that are associated with them. Many larger corporate dental companies will have their dental offices accept these plans because they are offered a capitation check once a month. These are large checks that are deposited by corporate big wigs that allows them to profit large amounts of money through the course of the year because of their willingness to accept these plans. Your employer will also accept these DHMO plans because it costs less to purchase them versus a PPO. Lastly, these plans normally provide you with a dentist that accepts your particular plan. If you want to see your own doctor, you will have to call and see if your dentist accepts that particular plan.

What is a waiting period?

Some dental insurance carriers will make you wait a period of time after signing up with them before your insurance benefits can be applied towards any dental treatment. Most waiting periods span from 6 months all the way up to 2 years.

How do dental insurance companies make money?

They collect money from individuals and employers every month, or every annual year, and they do everything they can to avoid covering treatment. DHMO plans are popular because larger companies provide them for their employees, and many larger dental corporate companies accept them. Many of these insurance companies make record profits year in and year out without any repercussions.

How does it work when you have two dental insurances?

If both of the plans are PPO plans, then your primary insurance is the one your employer provides you, while the secondary plan is the one that is normally under your spouse. A lot of times both insurances will cover your treatment. Normally the primary will pay the dentist, and whatever the primary did not pay for, your secondary insurance will cover. The primary has to pay the dentist first before a second claim is submitted to the secondary insurance. Your dentist will explain the details of your plan at your examination appointment.

Remember, this only works if both insurances are PPO plans. If one of the plans is a DHMO, these work separately, so you have to decide which plan you want to move forward with. You can still see a PPO providing dentist if your spouse carries that plan. Just let the dental team know that the plan is under your spouse.

What do you do when you are maxed out of your dental insurance?

If you have a PPO plan, and need a lot of dental treatment, your benefits may max out relatively quickly. Your dental team may recommend for you to get as much work done that is covered under your insurance until the following year when your benefits renew. They may also place you on a dental savings plan if your work can’t wait. Talk to your dental team to see what options are best for you.

Our team at Best Dental hopes the article shines some light on how dental insurance works. For any further inquiries please contact our team today.