Wednesday, November 26, 2014

Dental Insurance Part 1

The end of the year always has two groups of people in a dental office.  Those with remaining benefits and those waiting until they get new benefits.  
I thought it might be fitting to do a few pieces about dental insurance as best I can and post it here on the blog as a resource for those wanting it.
In the mid-1950s dental insurance came to be.  It was actually a pretty straightforward way to try and increase availability to dental care.  The move was actually led by dental organizations in California, Oregon and Washington and over time became what we call Delta Dental.  Delta Dental has changed over the years and isn't exactly the same organization, but is still the largest insurance carrier for dental benefits.  Especially here in California.

Back when Delta started most plans had an annual maximum of about $1000-$1500 per person per year.  This is when the average cost of a dental crown was about $100.

Here in 2014 there are a seemingly infinite number of plans that are out there and an equally large number of insurance companies.  Funny thing is, most have an annual maximum of about $1000-$1500 per person per year.  (Anyone thing the premiums for these plans have stayed the same?).  For those keeping track at home, the average cost of a crown today is a little over a $1000.  Are we getting the same bang for our buck?

To complicate things further, there are really 3 main types of dental insurance.  

Indemnity Plans are what most people think they have, but very few actually do.  These plans do not have networks.  They pay for services that are performed at set percentages (varies by plan) at a dentist of your choosing.  In most cases, dentists will bill the insurance for you and accept assignment so you pay only your copay and the insurance company will pay the dentist the rest of the fee.

The most common type of plan is the PPO (preferred provider plan).  This plan is similar to the indemnity plan as you do have some choice in who you can have as your dentist.  Some plans are what is called an EPO (exclusive provider option) that companies market as a PPO, but they may not provide any benefits to your chosen dentist.  The PPO plan allows you to choose who you can see, however, they have some dental networks.  In network dentists have agreed to accept lower fees for those who have the plan in exchange for those companies to try and encourage them to go to their office.  Some insurance companies networks offer fees to dentists that are pretty close to what is termed UCR (usual, customary and reasonable), other insurances offer fees that are significantly lower.  The better your insurance pays, the more dentists who will have signed up for it.  Our office plan is to work with insurances who provide fee schedules that we can provide quality dentistry for.  We personally have chosen to not have different materials, different labs and different quality of work for different insurances.  It is unethical and something we don't want to be part of.  Most PPO plans will still allow you to see your preferred dentist and your benefits are the same, but the the dentists regular fees.  Some plans make it difficult to see an out of network dentist.  We always  are willing to do a benefits check for anyone so you know what we know about your plan.  

The last type is a HMO plan.  We do not participate in any of these plans and there are fewer dentists who do than the other types.  Most likely, you will be assigned a provider.  In our area, the dental chains are the primary providers for these plans (Bright Now!, Brentwood Smiles, Western Dental) although there are a few other offices that will be part of these plans.  Here a dentist will get paid a monthly fee for being your dentist and in return you get your dental care from that office.  Typically, HMO plans will cover very limited services.  The patient will have the choice to get these services and is typically pressured to upgrade to different types of treatment that is not covered by the insurance and has a higher fee.  Sometimes, the treatment that is covered is not something that any dentist would recommend, other times the fees for the covered service at HMOs are so low that the dentist will lose money on the deal.  Our recommendation is that is you have an HMO, try and get a different type of plan.  You deserve choice in who you see.  The most common HMO we see is DeltaCare USA which is administered by Delta Dental, but still assigns you a dentist.  There are probably some good offices that accept HMOs, but there are a lot of bad ones too that have a corporate bottom line.

In general, there are 3 entities that decide the oral health care for patients with insurance.  You are one.  Your dentist is another.  The third is the insurance company who is trying to not have you get any work done.  We will give a little more information on how your insurance benefits are given in another post.  

Interesting fact, while dental insurance was started to increase oral health care access, it hasn't done much more than complicate things.  In the 1960's it was estimated that 50% of people had visited a dentist in the previous year.  Currently, it is estimated that only 47% have visited a dentist in the previous year.  I don't think its working.  I'm guessing a lot of patients have been scared off from dentistry.  Maybe the grew up with an HMO plan.

4 comments: