Dental insurance
Encyclopedia
Dental insurance is a type of health insurance
designed to pay a portion of the costs associated with dental care
. There are several different types of individual, family, or group dental insurance plans grouped into three primary categories: Indemnity (or sometimes called: true dental insurance) which allows you to see any dentist you want who accepts insurance, Preferred Provide Network dental plans (PPO; briefly discussed below), and dental Health Managed Organizations (DHMO) in which you are assigned to an in-network dentist or in-network dental office and must stay within that network to receive your dental benefits.
Generally dental offices have a fee schedule, or a list of prices for the dental services or procedures they offer. Dental insurance companies have similar fee schedules which is generally based on Usual and Customary dental services, an average of fees in your area. When a dentist signs a contract with a dental insurance company that provider agrees to match the insurance fee schedule and give their customers a reduced cost for services, this is considered an In-Network Provider or Participating Provider network (PPO). Depending on your specific plan, if you seek an Out-of-Network or Non-Participating Provider, any difference of fees will become the financial responsibility of the patient unless otherwise specified in your dental policy. Some dental insurance plans may have waiting period
restrictions. This is a period of time before certain benefits will be covered. Often set in place when you are a new enrollee or seek out an independent plan outside of an employer or group.
Dental insurance plans may have an annual maximum benefit limit and after that maximum benefit additional treatments become the patient's responsibility. Each year that annual maximum is reissued. The reissued date may vary as a calendar year, company fiscal year, or date of enrollment based on your specific plan. Orthodontics
usually has a separate limit. Some plans may have an annual deductible
depending on the treatment rendered. After the deductible is met, the remaining fee is then paid at its specified percentage or fee schedule.
Dental insurance companies set services or procedures into categories and refer to them with American Dental Association (ADA) codes. As an example, Preventative and Diagnostic procedures often include exams, x-rays
, and basic cleanings or prophylaxis. Basic procedures often include fillings
, periodontics
, endodontics
, and oral surgery
. Major procedures often are crowns
, dentures
, and implants
. Procedures such as periodontics, endodontics, and oral surgery may fall into the Major category depending on your specific plan with specific fee schedules and co-payments. Many dental insurance plans offer free semi-annual preventative treatment. Fillings, crowns, implants and dentures may have various limitations.
The enrollment process varies but often members are assigned an identification or policy number. When dental treatment is rendered a claim for services is filed with the dental insurance company. Eligibility of Benefits, or EOB, statements are most often then sent with payment to both the provider of service and the plan policy holder.
Upon enrollment, be informed through the enrollee benefit packet regarding coverage and contact a dental provider and/or dental insurance company with additional questions about specific dental benefits.
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...
designed to pay a portion of the costs associated with dental care
Dentistry
Dentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is widely considered...
. There are several different types of individual, family, or group dental insurance plans grouped into three primary categories: Indemnity (or sometimes called: true dental insurance) which allows you to see any dentist you want who accepts insurance, Preferred Provide Network dental plans (PPO; briefly discussed below), and dental Health Managed Organizations (DHMO) in which you are assigned to an in-network dentist or in-network dental office and must stay within that network to receive your dental benefits.
Generally dental offices have a fee schedule, or a list of prices for the dental services or procedures they offer. Dental insurance companies have similar fee schedules which is generally based on Usual and Customary dental services, an average of fees in your area. When a dentist signs a contract with a dental insurance company that provider agrees to match the insurance fee schedule and give their customers a reduced cost for services, this is considered an In-Network Provider or Participating Provider network (PPO). Depending on your specific plan, if you seek an Out-of-Network or Non-Participating Provider, any difference of fees will become the financial responsibility of the patient unless otherwise specified in your dental policy. Some dental insurance plans may have waiting period
Waiting period
A waiting period is a period of time which one must wait in order for a specific action to occur, after that action is requested or mandated.The term is commonly used in reference to gun control in the United States, where some U.S...
restrictions. This is a period of time before certain benefits will be covered. Often set in place when you are a new enrollee or seek out an independent plan outside of an employer or group.
Dental insurance plans may have an annual maximum benefit limit and after that maximum benefit additional treatments become the patient's responsibility. Each year that annual maximum is reissued. The reissued date may vary as a calendar year, company fiscal year, or date of enrollment based on your specific plan. Orthodontics
Orthodontics
Orthodontics, orthodontia, or orthodonture is the first specialty of dentistry that is concerned with the study and treatment of malocclusions , which may be a result of tooth irregularity, disproportionate jaw relationships, or both...
usually has a separate limit. Some plans may have an annual deductible
Deductible
In an insurance policy, the deductible is the amount of expenses that must be paid out of pocket before an insurer will pay any expenses. It is normally quoted as a fixed quantity and is a part of most policies covering losses to the policy holder. The deductible must be paid by the insured,...
depending on the treatment rendered. After the deductible is met, the remaining fee is then paid at its specified percentage or fee schedule.
Dental insurance companies set services or procedures into categories and refer to them with American Dental Association (ADA) codes. As an example, Preventative and Diagnostic procedures often include exams, x-rays
Dental radiography
Dental radiographs, commonly referred to as X-ray films, or informally, X-rays, are pictures of the teeth, bones, and surrounding soft tissues to screen for and help identify problems with the teeth, mouth, and jaw. X-ray pictures can show cavities, cancerous or benign masses, hidden dental...
, and basic cleanings or prophylaxis. Basic procedures often include fillings
Dental restoration
A dental restoration or dental filling is a dental restorative material used to restore the function, integrity and morphology of missing tooth structure. The structural loss typically results from caries or external trauma. It is also lost intentionally during tooth preparation to improve the...
, periodontics
Periodontology
Periodontology or Periodontics is the specialty of dentistry that studies supporting structures of teeth, diseases, and conditions that affect them...
, endodontics
Endodontics
Endodontics is one of the dental specialties recognized by the American Dental Association, Royal College of Dentists of Canada, and Royal Australasian College of Dental Surgeons, and deals with the tooth pulp and the tissues surrounding the root of a tooth...
, and oral surgery
Oral Surgery
Oral Surgery is a recognized international specialty in dentistry. It includes the diagnosis, surgical and related treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the head, mouth, teeth, gums, jaws and neck.It involves,...
. Major procedures often are crowns
Crown (dentistry)
A crown is a type of dental restoration which completely caps or encircles a tooth or dental implant. Crowns are often needed when a large cavity threatens the ongoing health of a tooth. They are typically bonded to the tooth using a dental cement. Crowns can be made from many materials, which...
, dentures
Dentures
Dentures are prosthetic devices constructed to replace missing teeth, and which are supported by surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable, however there are many different denture designs, some which rely on bonding or clasping onto teeth or dental...
, and implants
Dental implant
A dental implant is a "root" device, usually made of titanium, used in dentistry to support restorations that resemble a tooth or group of teeth to replace missing teeth....
. Procedures such as periodontics, endodontics, and oral surgery may fall into the Major category depending on your specific plan with specific fee schedules and co-payments. Many dental insurance plans offer free semi-annual preventative treatment. Fillings, crowns, implants and dentures may have various limitations.
The enrollment process varies but often members are assigned an identification or policy number. When dental treatment is rendered a claim for services is filed with the dental insurance company. Eligibility of Benefits, or EOB, statements are most often then sent with payment to both the provider of service and the plan policy holder.
Upon enrollment, be informed through the enrollee benefit packet regarding coverage and contact a dental provider and/or dental insurance company with additional questions about specific dental benefits.