Dental Insurance

"Since 1995 GroupComm Systems has used the services of BenefitsMart. During that time we have reduced our benefits costs by evaluating our coverage each year. They are thorough, accurate, and always keep our bests interests in mind. I would highly recommend their service."

Gerald Levy
Benefits Manager
GroupComm Systems

Dental plans have become one of the nation's most popular employee benefits. Most of the U.S. population visits a dentist at least once a year.

Dental Benefits

: Dental benefits can be managed by insurance company, self insured and administered by the employer or through a third party administrator, and a group practice or HMO-type plan.

Covered Dental Expenses

These are the nine professional treatment categories:

Diagnostic. Examination to determine the existence of dental disease. X-rays and routine oral examinations fall into this category.
Preventative. Procedures to preserve and maintain dental health. Topical cleaning, space maintainers, fluoride treatments fall into this category.
Restorative. Procedures for the repair and reconstruction of natural teeth.
Endodontics. Treatment of dental-pulp disease within existing teeth. Root canal therapy is an example of this type of procedure.
Periodontics. Treatment of the gums and other supporting structures of the teeth, primarily for maintenance or improvement of the gums.
Oral Surgery. Tooth extraction and other surgery of the mouth and jaw.
Prosthodontics. Replacement of missing teeth and the construction, replacement, and repair of artificial teeth and similar devices.
Orthodontics. Correction of abnormal tooth position through repositioning of natural teeth.
Pedodontics. Treatment of children who do not have all their permanent teeth. In addition to these nine areas, the typical dental plan also includes provision for palliative treatment (i.e., procedures to minimize pain, including anesthesia), emergency care, and consultation.

These nine different types of procedures are usually categorized into three or four general groupings for purposes of plan design. Following are the four groupings of coverages in the dental policies.

Preventative - preventative and diagnostic expenses. These are types of dental services most members receive during a routine dental checkup or visit.
Basic- all minor restorative procedures, endodontic, periodontic and oral surgery expenses. To restore decayed or fractured teeth; remove diseased or damaged natural teeth; treat oral disease; and repair dentures, bridges, crowns, inlays and onlays.
Major - major restorative work (e.g., Prosthodontics) These services are to replace missing natural teeth with artificial ones and to restore severely decayed or fractured teeth.
Orthodontic - orthodontic expense

Pedodontic care generally falls into the first two groupings.

Types of Plans

: There are usually two major types of dental plans being offered to employees; scheduled and non-scheduled plans. The two most popular types of plans are:

: Scheduled plans - Scheduled Plans are categorized by a listing of fixed allowances for each procedure. For example, the plan might pay $40 for a cleaning and $400 for root canal therapy. In addition, the scheduled plan might include deductibles and coinsurance.

: Non scheduled plans are usually referred to as comprehensive plans. They cover some percentage of the "reasonable and customary" charges, or the charges most commonly made by dentist in the community. This means that the usual and customary charge level will cover the full cost of the procedure for the 90 percent of the claims submitted in that geographical area. To contain cost, some insurance company may consider 70 or 80 percent of the claims as the definition of "reasonable and customary" charges. It is wise to inquire about the definition with the specific insurance company. Nonscheduled plans generally include a deductible, typically a calendar-year deductible of $25 or $50, and reimburse at different levels for different procedures. Preventive expenses typically are covered in full or at very high reimbursement levels. Reimbursement levels for other procedures usually are then scaled down from the preventive and dignostic level.

A typical plan will look like the following; this is just an example:

Deductible $50 for single and $150 for a family.
Preventative coverage is at 100%. The deductible is waived.
Basic coverage is covered at 80%. The deductible will be applied first, then the expenses are covered 80% by the insurance company and 20% is responsible by the member/insured.
Major coverage is covered at 50%. The deductible will be applied, then the expenses are covered 50% by the insurance company and 50% is responsible by the member/insured.
Preventative, basic and major coverages usually have an annual maximum of benefit (i.e., $1,000 a year)
Orthodontic coverage is covered at 50%. The deductible will be applied, then the 50% of the expense will be covered by the insurance company and the 50% is responsible by the member/insured. There usually is a lifetime maximum for this benefit (i.e. $1,000 lifetime maximum)

There are many different ways to write the dental policy under the nonscheduled plans. The deductible, coinsurance, and annual maximum dollar amount of benefit can vary. Orthodontic coverage can have different deductible, coinsurance, and lifetime maximums. The deductibles may or may not be applied to preventative coverages. The coinsurance will vary from 50% to 100% and the annual maximum on the coverage can vary from $500-$2,000. In addition, the policy can be written with and with out Major benefit or orthodontic benefit.

With the rise in dental cost, managed dental plans like PPO and HMO plan designs are becoming popular with networks of dentists. Plan designs are written so there is an incentive for the member/insured to stay in the network. (The handbook of employee benefits by Jerry S. Rosenbloom)

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