Which Type of Dental Insurance Is Right for You?
As the needs of employers, patients, and the marketplace continue to evolve, dental insurance and dental plans are also adapting. When it comes to ensuring lasting dental health for you and your family, the key is to establish a strong rapport with a dentist you feel comfortable with and stick with them. While insurance coverage may change, your relationship with your trusted dentist and their staff is likely to remain constant.
Today there are 4 major types of dental insurance:
- Indemnity Type
- Preferred Provider Organizations (PPO)
- Direct Service Organizations (DSO)
- Membership Plans (In Office Benefit Plans)
This is the classic type of insurance that has co-pays, deductibles and benefit limits. It also is the most expensive for the employer because it has no cost controls or gate keepers. Dental insurance is rarely sold to individuals due to overutilization.
Preferred Provider Organizations (PPO)
Preferred Provider Organizations (PPO) evolved in the 1990’s, offering the employer lesser premiums for coverage, but fewer network providers. The provider would take a reduced fee with the hope of attracting more patients. This type now dominates the new and renewal of dental contracts.
Direct Service Organizations (DSO)
Direct Service Organizations (DSO) are a newer type of dental Insurance offered to the public with corporation and/or venture capital groups (Heartland, Aspen and others) employing dentists and operating clinics. This type is the least expensive and subsequently offers the least treatment options. Coverage is only available at a corporate facility. Because it is a corporate entity, most providers have no ownership potential. This leads to younger, often less experienced providers. Many clinics experience significant turnover of doctors and staff.
Membership Plans (In Office Benefit Plans)
Membership Plans offer a new choice. This is not insurance, but a benefit plan. For a fixed monthly fee, the patient receives most preventive and diagnostic procedures for free and non-covered procedures at a fixed reduction. The dentist controls the fees and services offered. The conventional insurance company has administrative costs or profit margins that are eliminated in this plan. This type of coverage is generally offered by your existing provider and may not be open to the public on a large scale.
Is a PPO Dental Insurance, Premier or HMO Better for You and Your Family?
There are thousands of dental insurance plans out there, and it can be difficult and confusing to select the one best for you and your family. As for patient coverage and benefits, however, it is almost always wiser to choose a PPO dental insurance plan than an HMO or Premier.
What’s the Difference?
HMO is a common type of insurance. It can be cheaper than a PPO depending on the plan chosen by your company, and you will not have an annual deductible to meet. However, with an HMO dental insurance plan, you are always required to pay a specific fee (listed in your benefit booklet) for every single type of visit to your dental office.
Also, with an HMO plan, you are required to only visit the dentists specifically listed by your dental insurance, and there typically aren’t many in the area who are contracted with an HMO plan. This means that even though you are paying for coverage, you won’t get it if you have to see a dentist outside of your HMO network, which can often happen. This is why it’s always wise to see if you are allowed out of network benefits for a specific plan before you sign up for it.
With a Premier dental insurance plan, unlike with an HMO, you do have an annual deductible and maximum. However, the deductibles are very small; they can range from $25 to $100, and only need to be met once per benefit year.
When you visit a dentist that is in network for your Premier dental insurance plan, you may still pay a co-insurance (percentage) of certain services, but because of this contractual agreement, the difference between the office fee charged and the allowed amount is written off.
However, Premier plans tend to benefit the dentists more than the patients, which is why so many dentists are contracted with Premier plans. True, these dentists have signed a contractual fee schedule, meaning there is a fee limit for nearly every code used, and they cannot charge Premier patients a cent over those fees. Many of these fees are as high if not higher than the standard fees being charged at a dental office, meaning you might not be saving anything.
With a PPO dental insurance plan, unlike with an HMO, you do have an annual deductible and maximum. Deductibles are still relatively low; they can range from $25 to $100, and only need to be met once per benefit year.
When you visit a dentist that is in network for your PPO dental insurance plan, you may still pay a co-insurance (percentage) of certain services, but because of this contractual agreement, the difference between the office fee charged and the allowed amount is written off. With a PPO plan, these contractual fees are usually much lower than the fees being charged at the majority of dental offices.
There Are Many In and Out of Network Providers Accepting Your Plan
Similar to the HMO, for a Premier and a PPO dental insurance plan, a patient must go to a dentist who is contracted with their insurance plan in order to receive the best benefits. However, unlike with an HMO, you are free to visit any dentist you choose; you can even visit an out of network dentists if you need to and still receive some coverage if that dentist accepts your dental insurance company (Delta Dental, Metlife, Humana, etc, etc.). With an HMO plan, if you visit an out of network provider for any reason, you will get zero coverage for everything you have done no matter what.
Why a PPO Dental Insurance Is Better for Patients
As stated before, most dentists are not contracted with HMO dental insurance plans. If you are trying to decide between a Premier and a PPO dental insurance plan, here is a breakdown of a general cost for you, the patient, for a typical dental procedure:
Let Us Help
We know that choosing the right dental insurance plan is extremely important to ensure the best coverage for your family. If you are looking into purchasing a dental insurance plan or switching from one to another, we can look at your options with you and help you understand them. We can provide you with the right questions to ask the potential dental insurance company as well as explain any terminology you may be unfamiliar with. Call our office today (608) 274-9077 and we will always be happy to help!
We are a Delta Dental PPO provider and would be happy to see you at our East or West Clinic. Schedule an appointment today.
Commonly Asked Dental Insurance Questions
“Does Affiliated Dentists accept my dental insurance?”
We are providers for almost all insurance companies. However, it is highly recommended you call the insurance company before making your first appointment. (If you’ve already done that, you can request an appointment online.) Your dental insurance rep will help you find out what area dental clinics accept your specific plan.
Scroll below or click here for a list of all the insurances our offices accept. Please note this list shows all accepted insurances, both in and out of network.
“What is the difference between in network and out of network?”
- In Network Provider
Affiliated Dentists is an in network provider for many insurances. This means we have signed a contract with those specific insurance companies saying we agree to charge you a lower contracted rate than our standard office fees. Another benefit of seeing in network providers is even if your insurance doesn’t cover a certain procedure at all (i.e. crowns, implants, etc) we will still submit it to your insurance company so you still get a discounted rate off your out of pocket portion.
- Out of Network Dentist
An out of network dentist is not contracted with certain dental insurances meaning insurance pays less or nothing at all to the dentist for any procedures. This means you may be left with a much larger out of pocket portion for work done at an out of network dental office.
“How do I know if your office is in or out of network with my dental insurance?”
The best and quickest way to figure this out is to call your insurance company. Ask them to tell you what dental clinics in your area are in network with your specific plan. You might have Delta Dental Insurance which our office accepts, but as there are literally thousands of different plans just under Delta Dental of Wisconsin alone, our staff cannot know your specific coverage. When you call your insurance company, they will not only be able to tell you which offices are in network, but they can also tell you an entire breakdown of your benefits, what your yearly maximum is, if you have an annual deductible and more.
Once you have become an established patient at Affiliated Dentists, our staff can send a pre authorization of any treatment that has been diagnosed to your dental insurance. This will give you a better idea of what they will cover. This is highly recommended for treatment such as fillings, crowns, implants or periodontal cleanings.
“Will my medical insurance cover any dental work at your clinic?”
There are very few health plans out there that cover dental work, but they do exist. When you sign up for your medical insurance initially, it should say in your Explanation of Benefits informational packet sent to you whether or not any dental work is covered. Very few medical plans will cover dental work, and most of the time it’s only when caused by some sort of accident. The only way to know is if you check your Explanation of Benefits packet or call your medical insurance and ask.
“But wait, why don’t you put my medical insurance on file anyway?”
Because dental coverage is so extremely rare on medical insurance plans, our staff will not ask for your medical insurance card. If you know you have dental coverage on your medical insurance, it is your responsibility to let us know (but make sure that dental coverage is accepted at our office first by calling your medical insurance company and asking!).
If you are diagnosed for an appliance to help you with TMJ or teeth grinding, it might be covered by your medical insurance and not your dental insurance. If this is diagnosed for you, our staff will then ask you for your medical insurance information.
“Is there a discount for out of pocket payers who do not have dental insurance?”
Yes. For those who do not have dental insurance, we offer a 5% discount on all services. We do require payment on the day of treatment.
Insurances We Accept at Affiliated Dentists Madison:
- AETNA PPO
- AETNA DENTAL ACCESS
- AMERICAN DENTAL PROFESSIONAL
- ANTHEM (BLUE CROSS BLUE SHIELD)
- DELTA DENTAL PPO AND PREMIER
- DENTAL CARE ADVANTAGE (With copayments due day of service.)
- DENTAL HEALTH ALLIANCE (DHA)
- DENTAL WELLNESS PARTNERS
- CONNECTICUT DENTAL
- CONNECTION DENTAL
- GROUP HEALTH
- HUMANA ACCESS
- TRICARE (METLIFE)
- USA DENTAL (With copayments due day of service.)
- UNITED HEALTHCARE (UHC)
- UNITED CONCORDIA
Insurances We Do Not Accept at Affiliated Dentists Madison
- MEDICAL ASSISTANCE
- PHYSICIANS PLUS
If you have any questions, please contact the insurance customer service line on the back of your insurance card. If you do not have insurance, please call our offices and we can answer questions related to your first visit. Schedule an appointment online today.
How to Transfer Your Records to Affiliated Dentists
Once you have an appointment set up at one of our offices, all you have left to do is have your most recent x-rays transferred to our clinic. To do that, please contact your old dental clinic and let them know you are going to a new office. They will need you to sign a document authorizing them to release your records from their clinic for HIPAA policies. Once they are signed for, you can have them mail us the x-rays or email them to us directly. If they will be emailed, make sure they are sent to the correct clinic: [email protected] or [email protected]. And that’s it!
Now all you have to do is relax until your appointment!