Insurance Overview

Dental Insurance Coverage Options

Before you select a dental insurance plan, it's important to understand the differences between available alternatives so you can avoid surprises and better appreciate the value of what you choose.

Group insurance plans versus individual plans

Most people obtain dental insurance coverage through an employer, which is usually your best option when it is available. However, there are other alternatives including union or association-sponsored insurance plans, individual insurance plans, dental discount or "access" plans, government-subsidized plans, or membership plans offered directly by dental practices.

Group dental insurance plans offered through employers or other groups tend to cover services with fewer exclusions, waiting periods, or other restrictions than individual dental plans. This is because people pursuing individual policies are more likely to be doing so because they need immediate or significant dental treatment.

Plans without a provider network

Some dental insurance plans, broadly known as indemnity insurance plans, provide reimbursement for dental treatment performed by any licensed dentist. Because indemnity insurance plans do not offer access to a network of dentists who have agreed to discount their fees, the premium for these plans is often significantly higher than plans that provide the opportunity to visit a discounted in-network dentist. Some indemnity insurance plans may offer you an option to visit a network of dentists, but these network dentists generally do not reduce their normal treatment fees nearly as much as those that participate in managed care networks such as Preferred Provider Organizations (PPO) or Dental Health Maintenance Organizations (DHMO).

Preferred Provider Organization (PPO) plans

Like indemnity insurance plans, Preferred Provider Organization (PPO) plans allow you and your covered dependents to visit any licensed dentist and be eligible for benefits. The difference is that PPO plans also provide members access to dentists that agree to reduce their fees and not charge them for anything above those reduced fees. If they do, this is called "balance billing" and is prohibited.

Your out-of-pocket costs will likely be lower when you visit an in-network dentist. This is because PPO plans typically base coverage on a percentage of the lower cost of treatment you receive after any deductible has been met. Since in-network dentists have agreed to charge less, you pay less. Some PPO plans further incentivize members to seek care from in-network dentists by reducing the plan coverage for treatment received from out-of-network dentists.

In addition, plan members can realize a greater sense of confidence in the qualifications and reliability of in-network dentists because in-network dentists generally undergo a review process known as credentialing. Your plan's administrator or an independent third party reviews a variety of data sources to ensure that the dentist meets important standards. This includes a review of the dentist's license and specialty certifications (such as periodontists, endodontists, pediatric dentists, oral surgeons, or prosthodontists), liability coverage, malpractice history, and more. This process is repeated every two or three years.

Dental Health Maintenance Organizations (DHMO)

Dental Health Maintenance Organizations (DHMO) generally require you to select a primary dentist from their network. You will need to receive care from this dentist to be eligible for benefits. In return, these DHMO plans pay these dentists a monthly fee called capitation. When you require care from a specialist such as a periodontist, endodontist, pediatric dentist, or oral surgeon, you must obtain an authorization from your primary dentist.

Some DHMOs may not require you to select a primary dentist or obtain an authorization for care from a specialist. These plans are called open-access plans.

DHMO networks tend to be much smaller than PPO networks but coverage is often less expensive than a PPO or indemnity insurance plan. Plus, coverage levels may be stronger. Many DHMOs do not have annual maximums, although co-payments, deductibles, limitations, and exclusions may still apply. Review your open enrollment materials and benefit plan summary carefully to clearly understand the plan benefits and your obligations. Similar to PPO plans, dentists who participate in a DHMO undergo a review process known as credentialing.

DHMO benefits for treatment provided by an out-of-network dentist are generally limited to emergency care only.

Dental discount or "access" plans

A dental discount plan is not insurance and does not provide benefit reimbursement. For a monthly or annual fee, dental discount plans offer members access to a network of dentists that have agreed to discount their treatment fees. Members pay the full cost of the discounted fee directly to the dentist. Because there is no reimbursement from a plan administrator, there are no claims to submit. This inhibits plan administrators from monitoring dentist treatment and billing behavior.

Membership plans

Dentist membership plans provide dental coverage to patients of a specific dental practice. Because these plans are offered directly by the dentists themselves, any services you receive from other dentists are generally ineligible for reimbursement. It is important to consider that these plans lack oversight from a plan administrator or third party who monitors dentist treatment and billing patterns.

Government plans

Government-sponsored insurance plans such as Medicaid and Children's Health Insurance Plans (CHIP) are available to those who qualify based on their financial situation or disability status. There are also privately offered insurance plans like Medicare Advantage plans (Medicare part C) to which you may have access depending on your age or other factors. State or federal plan administrators can provide more information on how to access these types of plans.

Other considerations when choosing a plan

• What is most important to you: the dentist's location, confidence that your dentist is properly credentialed, or your out-of-pocket cost?
• Are you willing to change dentists to one who participates in a network that has agreed to charge rates well below the average rates in your area?
• Do you want a plan administrator that requires dentists to submit claims on your behalf, helps with any problems you may have, and offers additional tools to manage your coverage better?
• Do you have expected dental needs? If so, compare your monthly premium, deductibles, co-payments or coinsurance, annual plan maximums, and possible service limitations and exclusions before deciding which plan to choose. For more information, see the related article "Understanding how dental insurance plans work."

	Indemnity	PPO	DHMO	Discount or Access plan	Membership plan
Premium cost	Higher	Moderate	Lower	Lower	Varies
Who can I visit for care	Any licensed dentist	Any licensed dentist. Greater savings when care is provided by an in-network dentist	In-network dentists only with limited exceptions	Participating network dentists only	One dentist or practice group
Provides dental plan coverage	Yes	Yes	Yes	No	No
Screening of dentists and/or third-party oversight	Yes	Yes	Yes	Varies	Varies