A Consumer's Guide to Dental Insurance

Dental insurance can be a very confusing matter for most consumers. In this article I will try to explain the different types of insurance plans available and hopefully shed some light on this subject.

There are three basic types of dental insurance coverage:

Indemnity or private pay plan

PPO plans

Managed care (also called HMO or capitated plans)

Indemnity Dental plans are plans that allow the insured to use any dentist of their choice. Once you see the dentist they will bill your insurance and the insurance plan will pay a certain percentage of the fee. For example you see your dentist for a filling. The fee for the filling is $200, and the plan pays for 80% of that fee. So the insurance will pay $160, and the patient will pay $40. Indemnity plans are a bit more costly to get but offer the best coverage, and allow the patient to choose their own doctor. A majority of dentists accept this type of insurance.

PPO Dental plans are insurance plans that have negotiated the fees for various dental procedures with the dentists that are on their plan. So with PPOs, there is a list of dentists that the patient can choose from to go see. Some PPOs allow the patient to see non-panel dentists, but they usually pay less than if you were to see a panel dentist. So if a typical filling costs $200, a PPO insurance will negotiate the fee down to $150, and then they pay 80% of that. So in this case the insurance pays $120, and the patient pays $30. So the patient saves a little, but gives up some of their ability for choosing their own dentist. Depending on the part of the country, about 50% of all dentists participate in some PPO plans.

Managed Care Dental Plans were created to reduce the over-all cost of dental care. Unfortunately, what actually happens is that while it reduces the cost of having insurance (lower monthly premiums), it increases the patient's out of pocket expense in the long run. They way these plans work is that they pay a dentist a monthly fee (anywhere from $2 to $5 per patient per month) and that is it.

So the only way the dentist can make a living off $5 per month is that either he prays that the patient never comes in for treatment, or that if a patient does come in, he has to hope that the patient needs a lot of cosmetic services (that are not covered by most managed care plans), so that the patient ends up paying for service out of their own pocket. So, even though the patient pays less for their insurance premiums, they end up getting a whole lot less coverage. In my opinion managed care plans never accomplished what they were originally intended to do, which was to promote health and lower costs.

There are other types of coverage out there, such as discount dental plans that are usually advertised on the internet. Only participating dentists are covered by this plan, and the patient is responsible for the entire fee. The only benefit here is that if a filling usually costs $200, the dentist will extend a set discount to the patient based on his contract with the discount plan. So instead of $200 he may charge $120, but the patient is responsible for the entire $120.

It is very difficult to get dental insurance as an individual. The majority of dental insurance can only be bought as part of an employer group. The plans that are offered for individuals usually have many restrictions and limitations, and often have waiting periods of up to 12 months before they allow a patient to get any major treatment done. It is usually cheaper to just pay for the treatment.

So given the choice indemnity plans are the best types of insurance to have, followed by PPO's. Managed care plans should be avoided if possible.

If you would like to schedule an appointment, please contact Dr. Madison by calling (310)553-2940.

If you have any other questions or comments regarding this article, please contact us at (310) 553-2940 or by email at periodontics@earthlink.net.

Dr. Miles Madison, D.D.S., is an award-winning periodontist in Beverly Hills, California.