At NOLA Dentures and General Dentistry, one of the most frequent discussions in our office is about a person’s dental insurance or dental benefits. This series of blog posts will be about using 3rd parties to help cover the cost of dentistry from describing what they are to common terminology used by the companies and common problems that occur. My goal for these blogs is to inform you so that you know how to work with your insurance company to get the best possible care. For the first blog, I want to discuss what dental insurance is, the difference between PPO vs HMO, and whether you should sign up for it.
Dental insurance is not true insurance but rather a limited set of benefits that you receive through your carrier. Each year a subscriber gets a certain dollar amount that is covered in care per year, and it can range between 500 to 3000 dollars but the most common amount that we see is 1000 dollars. At the end of the year, the benefits reset and do not carry over year to year. All dental care is usually classified between preventative, minor, and major coverage and the distinction is important because that is how the insurance company decides how much to pay. For preventative care such as cleaning, the rate is usually between 80% to 100%. For minor care such as fillings, oral surgery, and periodontal therapy, it is usually between 50% to 80%. For major care such as dentures, crowns, and implants, it is between 20% to 50%. Also, each insurance policy has its own sets of limitations for things that they will and will not pay for which will be discussed in depth in the next blog.
Another important part of dental benefits is to understand if the plan is PPO or HMO. PPO stands for preferred provider organization, and with PPO insurance, typically a subscriber can go to any dentist of his or her choosing and then be reimbursed. The reimbursement rates vary depending on which dentist is chosen. HMO stands for Health Maintenance Organization which gives the subscriber a certain dentist to see for all their dental needs. If the subscriber wants to see a different dentist than the one on the plan, the subscriber must tell the carrier and see if the carrier will allow it. Generally, as a rule, PPO plans are more expensive than HMO plans as PPO plans allow for more options to use the benefits whereas HMO plans can severely limit a person’s options.
The final consideration is whether or not one should get dental insurance. Our experience is that dental insurance can be a good deal if you are getting it through an employer, but it is almost never a good deal if a subscriber signs up for an individual policy. For employer-sponsored plans, each plan is different and is tailored to what the company has chosen to cover. For example, a major dental carrier is Metlife, and with one company, Metlife might have a benefit that covers 3000 a year and major dental work at 50% whereas with another company it might only cover 1000 a year and not cover major dental work at all. Individual policies though generally are not as good as employer-sponsored plans. These policies tend to have severe limitations and we have seen some that allow no treatment beyond routine cleanings for the first 3 years. The carriers make these individual policies to prevent a person from getting the full benefit quickly and then quitting the insurance company after the full benefit has been
paid. If a person is considering purchasing an individual policy, we recommend saving money and just paying out of pocket for all dental care or using a financing company such as CareCredit or Compassionate Finance.
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At NOLA Dentures and General Dentistry, we encourage all our patients to make full use of their dental benefits. These benefits should be used fully as the subscriber is entitled to them. We also work hard at our office to help our patients understand their benefits as well as use them effectively each year so that the cost of dental care can be the lowest possible. If you’d like help with maximizing your benefits or understanding your insurance, give us a call today.