Dental Insurance and Open Enrollment

Hello! This is Teri, I’m the Office Manager at Today’s Dentistry. As it’s nearing the end of the year, I’ve asked Dr. Burneson if I could appropriate the column this month to discuss Dental Insurance and open enrollment. This article will involve purchased plans only, not Oregon Health Plan dental coverage.

There are two different ways to receive or purchase dental insurance. The first is through your employer; the second is on the open market. If you are offered insurance through your employer, it’s rare to have a choice, but it can happen. The open market has a huge variety of options. I hope that the following information will help you make the best choice for you and your family.

Terminology:

  • Fee Schedule: list of costs of all services provided in dentistry.
  • PPO: Preferred Provider Organization: Dental plans that have an agreement with individual dental offices where the office has agreed to accept the insurance company fee schedule, and not charge the patient the difference between that and the dental office fee schedule. EXAMPLE: Delta Dental, Regence, Cigna
  • DHMO: Dental Health Maintenance Organization: Dental plans that will only pay a specific provider for services. Instead of the office being paid for services provided, it’s paid a set amount monthly for every patient assigned to the office, regardless of if that patient was seen in the office. EXAMPLE: Willamette Dental, Delta Dental, Cigna (many companies offer both PPO & DHMO)
  • Fee for Service: Dental insurance that does not have a network. They will pay any dental office based on the insurance fee schedule, which usually (but not always) is within the fee schedule of most offices. The patient is responsible for any difference.

Information to have before choosing any insurance plan:

  • What type of plan is it?
    • If it’s a PPO plan, is your current dentist in-network?
    • If not, will the insurance pay your dentist anyway? Will they pay based on the fees the dentist bills, or based on the insurance fee schedule? Will they pay a lower percentage of coverage if the dentist is out of network?
    • If it’s a DHMO plan, are you willing to go to that office for treatment?
  • What limitations are there?
    • Are there waiting periods?
    • Are there procedures they don’t cover (crowns, implants, orthodontics)?
    • Do they pay a percentage of the fee billed or a flat dollar amount? If it’s a flat dollar amount, how does that compare to the fee your dentist will charge you?
    • How much is the annual deductible?
  • Is it actually an insurance plan, and not a discount fee schedule plan?
    • The difference is that insurance pays an amount based on what treatment is done. Discount fee schedule plans only allow you to pay a reduced fee to the dentist, there is no payment from an insurance company.

If you already have a dentist, their office can be the best resource for finding out if the plan you are a looking at would be a good fit for you. In my experience, there is nothing worse that having a patient present me with new insurance that doesn’t work in our office, doesn’t pay much towards treatment, or has limitations that our patients aren’t expecting. As the person who processes insurance in our office, I love the opportunity to discuss a patients’ choice before they choose.

For patients looking to buy insurance on the open market, my last suggestion would be to speak to your dentist and ask if they have any program, or discounts, for patients who don’t have insurance. In our office, we offer a membership plan that includes a yearly exam, x-rays, preventative cleanings (or periodontal cleanings for a co-pay), and provides a 20% discount for all other treatment. We are not the only practice in the Rogue Valley that offers this type of plan. I frequently will “run the numbers” for patients to see if purchasing dental insurance is a more cost-effective solution, so they know they are getting the best care at the best price. Usually, but not always, our in-house Dental Plan makes the most sense.

Please, please, please, if you DO have new dental insurance, provide that information to your office BEFORE your appointment! It will save you time if there is something unexpected about your new policy.

Dental insurance is a difficult product to understand exactly what you are getting for your money. I’ve expanded on this theme on our website, if you would like more information visit us at www.ashlanddentist.com, and click on the link for “Dental Insurance Information”. When choosing dental insurance, as with life, knowledge is power!