How Does Dental Insurance Cover Orthodontic Treatment
Dental insurance plans accepted by our St. Louis orthodontic office
Many of the patients at my St. Louis orthodontic practice often have questions about the types of dental insurance plans that are available, so I have decided to write a post about it to provide an overview of the topic.
There are a large variety of dental insurance plans, but they can generally be divided into two categories, which are managed and fee-for-service plans. The managed plans, including DPPO’s and DHMO’s which are explained below, usually operate by attempting to control or reduce the cost of providing dental services to patients. These types of arrangements are usually "closed panel" plans because they limit the dental professionals that a patient can visit. On the other hand, fee-for-service plans, often referred to as "traditional" or "indemnity" plans typically allow members to see any dentist of their choosing and fully or partially reimburse the dentist based upon the fees established by the dentist. These types of arrangements are usually "open panel" plans because a patient can choose to see any dental professional desired. That being said, at my St. Louis orthodontic office, we typically accept all forms of dental insurance, so if you have any questions about your eligibility please feel free to contact us. What follows is a brief description of the major types of dental insurance plans that are available and some common restrictions upon them:
Dental Preferred Provider Organizations
Dental Preferred Provider Organization (DPPO) programs are similar to medical PPO’s in that you do not need to choose a primary provider or get a referral to see a specialist. The plans operate by providing patients with a list of dentists in a network who have agreed, by contract, to discount their fees. Often, these programs will still allow patients to receive treatment from a dentist that is not in the network, however, the patient must usually pay higher deductibles and co-insurance fees. As a result of these cost containing measures, these types of arrangements are typically cheaper than fee-for-service plans that are described below.
Dental Health Maintenance Organizations
Capitation plans, often also referred to as Dental Health Maintenance Organization (DHMO) plans and pre-paid plans, are similar to medical HMO’s. Thus, when you join one of these plans, you usually select a primary care dentist, who then oversees your dental care and refers you to specialists in the network when necessary. These programs operate by contracting with specific dentists to pay a fixed amount per enrolled family or individual, regardless of whether the dentists’ services are used or not. Under this type of arrangement, the dentists agree to perform certain types of services for enrolled patients at no charge whereas a co-payment and/or deductible is/are usually required for all other services. As a result, this type of plan is typically the least expensive option for dental insurance.
With this type of traditional or indemnity insurance, you typically choose your own dentist, who performs services for you, submits a claim to your insurance company and the insurer either fully or partially pays the requested fees based upon the terms and conditions of your policy. You will pay the remainder of the fee as co-insurance.
Discount Dental Plans
This type of program, often referred to as a “reduced fee-for-service” plan is not dental insurance. Instead, this type of program arranges with a network of providers to agree to perform dental services for you at a discounted rate.
Dental Insurance Plans' Restrictions and Limitations
Dental plans are like medical plans in that they require participants to pay out-of-pocket costs like deductibles, co-insurance and co-payments:
- Deductibles are a flat amount that must be paid before any benefits can be received.
- Co-insurance is the amount of the total service fee that you must pay after the dental insurance plan reimburses a percentage of the fee to the dental professional. For example, if a dental insurance plan reimburses 90% of a certain procedure and it costs $100, then the patient is responsible for the remaining 10% or $10 as co-insurance. This type of arrangement is more common with fee-for-service plans and DPPO’s as explained above.
- Co-payments are usually small flat fees that must be paid at the time of service and are most common in capitation plans or DHMO’s as explained above.
Dental insurance plans however differ from medical plans in that they usually have a schedule of different reimbursement levels depending on the “class of service” that has been performed. There are four general classes of service:
- Class 1 includes diagnostic or preventative procedures, such as exams or x-rays and they are typically covered at the highest level of reimbursement (often at 100%) to encourage early care that prevents later and more expensive problems from developing.
- Class 2 includes basic procedures, such as fillings and periodontal work, and these procedures typically are reimbursed at a lower rate, such as 70-80%.
- Class 3 includes major and complex services, such as crowns and dentures, and these procedures typically are covered at 50% or less.
- Class 4 includes orthodontic treatments like the types that I perform at my St. Louis orthodontic office and you should be aware that many dental insurance plans do not include this class of procedures for reimbursement at all.
In addition, there are a number of other common limitations on dental insurance plans that you should be aware of:
- There are often limitations on the number of specific types of procedures that you can receive per year and be reimbursed, such as dental cleanings.
- There are often age restrictions for receiving certain procedures. For example, in many plans a patient cannot receive reimbursement for orthodontic procedures beyond their teenage years.
- There may be annual caps on the amount of money that you can be reimbursed for all dental procedures per year, whose dates are defined by the insurance plan and may be different from the calendar year, that is, it may not start in January and end in December.
- In addition, there may be lifetime caps on the amounts that will be reimbursed for complex procedures.
- For certain procedures there may be an “alternative benefit” provision, which means that the dental plan has defined alternative, lower cost dental services that provide a similar result. For example, if your dentist proposes a tooth-colored filling for a back tooth, your dental insurance may define an alternative procedure as a silver filling, which costs less. In such cases, if you choose the higher cost service, you will still be reimbursed for the lower cost service and then your out-of-pocket costs will be higher. This type of insurance restriction is also commonly referred to as the least expensive alternative treatment (LEAT).
- Certain procedures, such as cosmetic ones like tooth whitening, may not be covered at all.
- Many plans do not cover pre-existing conditions, such as missing teeth.
- There may also be time limits on replacements for certain complex dental procedures, such as for crowns and implants.
Finally, many dental insurance plans will only reimburse based upon "usual, customary and reasonable" (UCR) fees, which means that the plans determine what they consider to be the maximum amount that a dentist should charge for a given procedure and you will be reimbursed at no more than that set fee. In practice, this means that if your dentist is charging more than this amount for a specific procedure, you will only be reimbursed at the lower UCR fee and your out-of-pocket costs will be higher.