Dental insurance plans: Benefits calculations and copayments.
Dental insurance plans: What dental services are covered and at what level? Will a copayment be required?
You'll need to look at the specific terms of each of the dental insurance plans that you are considering to see what level of coverage is provided.
Capitation dental insurance plans (dental HMO's) typically cost the insured less out-of-pocket.
Dental health insurance plans (both dental HMO's and traditional indemnity types) typically provide coverage for different dental procedures at different rates. As an example, with capitation dental plans (dental HMO plans) examinations, x-rays and cleanings are typically provided for without a patient copayment (this can be somewhat common with indemnity plans too). Then, when other types of dental procedures are performed, a patient copayment will be required.
We will mention that despite the need to make a copayment for at least some types of dental procedures, that copayment that is required with a dental HMO plan for any particular dental procedure will typically be less that that required with a traditional indemnity dental insurance plan. This means that overall a capitation dental insurance plan will typically cost the patient less in terms of treatment out-of-pocket expenses. Of course, this depends on the specific terms of the individual insurance policies being compared.
Indemnity (traditional) dental insurance plans usually determine benefits in one of two basic ways.
» Table of allowances dental insurance plans.
Indemnity dental plans (traditional dental insurance) typically base the benefits that they provide either on the procedure's "UCR" fee (Usual, customary, and reasonable fee) or else a fixed fee schedule termed a "table of allowances." A table of allowances is simply a listing of all covered dental treatments and procedures and that amount that the dental insurance company will provide as benefits when they are performed.
If you are considering a dental plan that uses a table of allowances to determine benefits, you should inquire as to whether the insurance company payments specified in the table will be accepted by the treating dentist as payment in full, or you will be expected to make up the difference between this fee and the dentist's regular fee by way of making a copayment (the more likely arrangement). There can be a very significant out-of-pocket difference for the patient between these two scenarios. You absolutely must understand and know the answer to this point.
» Benefit calculations made using the dental service's UCR fee.
Those insurance company benefits that are based on procedure UCR fees (Usual, customary, reasonable fees) are calculated on a percentage basis. Some types dental procedures, such as those involving preventive or diagnostic dental procedures (cleaning, x-rays), may be covered at a very high rate (80 to 100%). More "basic" services (routine dental procedures) will be covered as a slightly lower percentage (50 to 80%). "Major" dental services, such as dentures and crown and bridge treatment, if covered, will typically be provided for at an even lower rate (50% or less). (We outline typical coverage for Preventive, Basic and Major services in greater detail here.) You will simply have to evaluate the different rates of reimbursement that are provided for by the different insurance policies that you are evaluating. These numbers absolutely will vary from plan to plan.
