More About Insurance Coverage
General Information
If the implant-based solution is superior, why is it generally
not covered by dental insurance plans?
Insurance companies have many practices and policies that are hard to understand. The fact of the matter is that insurance companies are in business to make money, not spend money. That is why so many hospitals are losing money and having to lay off personnel. Dental implants are covered under socialized medicine plans in Sweden and other countries. I would not base my opinion about the quality of a medically progressive treatment plan upon the evaluation of the insurance business. Rather, I’d place my trust in the professionals who are both educated and experienced in providing care.
Unlike medical disease, which can be both unpredictable and catastrophic, in general, most dental ailments are preventable. Preventive care, including regular checkups and cleanings, is the key to maintaining your oral health. With regular visits to the dentist, problems can be diagnosed early and treated without extensive testing or elaborate and expensive procedures. That keeps the costs of dental care much lower than those of medical care. In fact, total spending for dental care is decreasing. In 1970, it made up 6.3 percent of total health care expenditures. But in 1991, dental care's share of health care spending was only 4.9 percent.
Medical And Dental Benefits
Medical insurance is designed primarily to cover the costs of diagnosing, treating and curing serious illnesses. Dental insurance works differently. Most dental coverage is designed to ensure that the patient receives regular preventive
care. Because most dental disease is preventable, dental benefits plans are structured to encourage patients to get the regular, routine care so vital to preventing and diagnosing the onset of serious disease.
Third Parties
Dental Service Corporations. These not-for-profit organizations negotiate and administer contracts for dental care to
individuals or specific groups of patients. Delta Dental Plan and Blue Cross/Blue Shield Plans are examples of this third party type.
Insurance Carriers. These for-profit companies underwrite the financial risk of, and process payment claims for, dental services. Carriers contract with individuals or patient groups to offer a variety of dental benefits packages, often including both fee-for-service and managed care plans.
Self-Funded Insurers. These companies use their own funds to underwrite the expense of providing dental care to their employees. The company pays for the dental costs of its employees, usually with limitations on services and fixed-dollar allocations.
Indemnity Plans
Insurance companies usually pay between 50 percent and 80 percent of the dentist's fee for covered services; the remaining 20 percent to 50 percent is paid by the patient. These plans often have a pre-determined deductible, a dollar amount which varies from plan to plan, that the patient must pay before the insurance carrier will begin paying for care. Indemnity plans also can limit the amount of services covered within a given year and pay the dentist based on a variety of fee schedules.
Capitation Plans
This type of plan provides comprehensive dental care to enrolled patients through designated provider
dentists. A Dental Health Maintenance Organization (DHMO) is a common example of a capitation plan. The dentist is paid on a per capita (per head) basis rather than for actual treatment provided. Participating dentists receive a fixed monthly fee based on the number of patients assigned to the office. In addition to premiums, patient co-payments may be required for each visit.
Direct Reimbursement Plans
Under this self-funded plan, an employer or company sponsor pays for dental care with its own funds, rather than paying premiums to an insurance carrier or third party. The patient pays the dentist directly and, once furnished with a receipt showing payment and services received, the employer reimburses the employee a fixed percentage of
the dental care costs. The plan may limit the amount of dollars an employee can spend on dental care within a given year, but often places no limit on services provided. Patients can select a dentist of their choice and, in conjunction with the dentists, can play an active role in planning the treatment most appropriate and affordable to ensure optimum oral health.
Dental Plans Do Have Their Limitations
Today's health insurance, including your dental plan, is designed to help you get the care you need at a reasonable cost. Because each person's oral health is different, costs can vary widely. To control dental treatment costs, most plans will limit the amount of care you can receive in a given year. This is done by placing a dollar "cap" or limit on the amount of benefits you can receive, or by restricting the number or type of services that are covered. Some plans may totally exclude certain services or treatment to lower costs. Know specifically what services your plan covers and excludes.
There are, however, certain limitations and exclusions in most dental benefits plans that are designed to keep dentistry's costs from going up without penalizing the patient. All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes dental coverage and health insurance may overlap. Read and understand the conditions of your dental plan. Exclusions in your dental plan may be covered by your medical insurance.
Choose plans that impose dollar or service limitations, rather than those that exclude categories of service. By doing so, you can receive the care that's best for you and actively participate with the dentist in the development of treatment plans that give the most and highest quality care.
Although your dental benefits plan may not be bound to predetermined costs, this mechanism can help you and your dentist plan and budget a treatment plan appropriate to your oral health needs.
To help contain costs, your plan may limit your benefits by number of procedures and/or dollar amount in a given year. In most cases, particularly if you've been getting regular preventive care, these limitations allow for adequate coverage. By knowing in advance what and how much your plan allows, you and your dentist can plan treatment that will minimize your out-of-pocket expenses while maximizing compensation offered by your benefits plan.
Things To Consider When Choosing Your Dental Plan