Dental insurance premiums can be more expensive than simply paying out of your own pocket for routine checkups and cleanings. So if you’re one of the millions of Americans with no dental coverage, is a policy for your pearly whites worth the cost? The answer may depend on whether you expect to face aching bills for your teeth.
Most dental insurance policies emphasize prevention and diagnostics, typically covering two annual exams and cleanings, plus X-rays and, for children and older adults, fluoride treatments, says Evelyn Ireland, executive director of the National Association of Dental Plans, or NADP.
But the real benefit is being covered for bigger-ticket procedures, such as fillings, root canals and crowns, says Carrie McLean, a consumer specialist with eHealthInsurance.com.
“It’s like health insurance — you’re really buying peace of mind,” McLean says.
Fewer than 6 out of every 10 Americans had dental benefits in 2010, according to a report released in late 2011 by the NADP and Delta Dental Plans Association.
Dental policies vary widely, and choosing the right one can be tougher than remembering to brush twice a day.
What’s covered, what’s not
People with dental insurance commonly have what’s described as “100-80-50” coverage, meaning it pays 100 percent of the cost of routine preventive and diagnostic care, such as checkups and cleanings; covers 80 percent for fillings, root canals and other basic procedures; and 50 percent for crowns, bridges and major procedures, Ireland says.
The vast majority of coverage is provided through employee and group policies, plans that charged annual premiums of between $234 and $432 per person in 2011, according to NADP estimates.
The cost for you to buy an individual policy averages about $360 a year, McLean says.
Meanwhile, paying out of your own pocket for two exams and cleanings and a set of X-rays in 2011 would have cost about $370, on average, according to the American Dental Association.
For care that goes beyond the routine stuff, most plans cap coverage at $1,500 a year, although higher annual limits can be arranged by paying a higher premium.
Unlike health insurance, dental plans don’t bar coverage for pre-existing conditions, though some policies may restrict coverage for people with missing teeth.
Cosmetic dental procedures are rarely if ever covered by insurance, according to Ireland and McLean.
HMO, PPO or indemnity plan?
Dental insurance comes in three varieties: HMO, PPO and indemnity plans.
The HMO, or health maintenance organization, option restricts coverage to dental professionals within a limited network.
More popular are the PPO, or preferred provider organization, policies, which are similar to HMOs but allow patients to see dentists outside the “preferred” network. However, patients are typically charged reduced rates if they see an in-network dentist. Some 70 percent of dental policies are through PPOs, according to Ireland.
A third option, called an indemnity plan, allows a patient to see any dentist and typically picks up a percentage of the costs.
The advantage of PPOs over indemnity plans is that dentists within the PPO network typically agree to accept lower fees for procedures, according to Ireland. So, a crown that results in $500 in patient costs under an indemnity plan might mean $400 in out-of-pocket costs under a PPO plan.
“That’s the advantage of any plan with a network — there’s a negotiated discount,” Ireland says. “You’re paying based on the discounted rate. The doctor can’t bill you for the difference.”
Waits are a drawback to individual plans
One disadvantage if you’re considering buying any individual dental plan is that they often come with waiting periods that typically don’t apply to patients in group plans.
For example, most individual plans won’t cover fillings for the first six months of a policy and may not offer coverage for certain other procedures for up to 18 months, says McLean.
“The reason individual plans have waiting periods is because they’re not going to decline you, so what they do to stop you from getting the plan, getting a root canal and dropping the insurance is to have a waiting period,” McLean says.
Anyone exploring dental coverage may want to consider forgoing traditional insurance in favor of an alternative: a discount dental plan. You pay an annual fee in exchange for receiving certain services at a set rate or at a discount.
One example is Quality Dental Plan, created by Oregon dentist Dr. Dan Marut. He says patients pay an average of $249 a year for the preventive services typically covered by dental insurance — two exams, two cleanings and X-rays — as well as a teeth-whitening treatment that insurance rarely pays for. Members also can obtain additional procedures, such as fillings and root canals, at discounted rates.
“Lots of people don’t go to the dentist until something hurts — by that time, it’s already a problem,” Marut says. “Our goal is to get people in earlier.”
There are no waiting periods, and there’s no maximum on how much savings you can tally each year. But the services included in these plans vary widely, and the choice of dentists can be very limited. Figures supplied by Marut show his plan has a network of fewer than 200 dentists spread over 47 states.
Can you name your own price?
If you ultimately decide against buying dental insurance, or even if you’re already covered, you might ask your provider to take a bite off the bill by reducing the overall fee or your out-of-pocket costs.
“It’s always a good idea to get out of your comfort zone and negotiate,” McLean says.
If you’re paying completely out of your own wallet, ask to set up a payment plan. If you can pay in full, request a 10 percent discount.
“Dentists will work with you, especially if you’ve seen them for a long time,” she says.