Posted April 3, 2012
Dental insurance proposals often look similar on the surface. But when you dig into the plan details, you may be surprised to discover some important differences that could impact the coverage and services expected. Review the following 10 tips to help you evaluate dental benefits plans.
1. Location of Procedures – Most carriers list procedures in different categories, such as X-rays, endodontics (root canals), periodontics (gum disease treatment), or oral surgery; with a dental provider network, review the plan to determine whether these procedures are classified as preventive, basic or major as this will impact rates and out-of-pocket costs
2. Deductibles and Maximums – If the plan has a deductible, know the amount and when it applies; find out whether there is an annual family maximum and benefit limit; if orthodontia is included, know the lifetime benefit available
3. Coinsurance and Copayments – Determine the costs for in-network and out-of-network dental care; with a dental provider network,, know what percent the plan pays by procedure category, typically stated as preventive, basic or major; with DHMO prepaid plans, find out the members’ costs for common procedures
4. U & C Allowances – Verify the “Usual and Customary” allowance used for out-of-network providers; understand that the 80th percentile for one carrier may equal the 90th percentile for another; find out the resource the carrier uses for U & C data and how often the carrier updates its records
5. Frequency Limitations – Determine the approved frequency level for dental services by asking these questions:
- How often can each type of X-ray be taken?
- How many cleanings are permitted per year?
- How many years are allowed between crown replacements? (One carrier may approve replacement of crowns every five years, while another may extend the limit to 10 years.)
6. Waiting Periods and Participation – Verify whether some procedures require a waiting period before benefits can be used; know whether there is a different policy for current and new plan members; find out whether the carrier requires a specific percentage of eligible employees to participate in the plan
7. Additional Benefit Services –Check whether the plan covers dental implants, composite fillings in molars and whether the orthodontia coverage applies to adults, children or both
8. Network Access – If the plan includes a dental provider network, determine whether there are enough contracted providers to meet the needs of plan members; find out how the carrier counts network providers
9. Extra Value – Find out whether the carrier offers discounts for vision, hearing or pharmacy services that increase the value of dental benefits; extra non-insurance discounts generally are available at no additional cost to the plan premium
10. Commission – Verify the commission amount included in the dental plan cost since not every carrier quotes the same percentage amount
Adapted from an Ameritas Group article written for Health Insurance Underwriter, 2011; used by permission.