Before you select a dental plan, it is important to understand the differences between the different plans so you can avoid surprises and better appreciate the value of what you choose.
Most people obtain dental coverage through their employer. If this is not an option, there are other common alternatives, including union or association-sponsored plans, individual plans, government-subsidized plans, or membership plans offered directly by dental practices.
Group dental plans, such as employer or union/association-sponsored plans, tend to cover services with fewer restrictions than individual dental plans. This is because there are more people in a group insurance pool sharing the overall cost. In some cases, people choosing individual policies are more likely to be doing so because they need immediate or significant dental treatment. For this reason, individual plans often have waiting periods applied to certain services before the plan covers those services.
Preferred Provider Organization (PPO) dental plans allow you and your covered dependents to visit any licensed dentist and be eligible for benefits. PPO dental plans provide members access to dentists that agree to reduce their fees and not charge them for anything above those reduced fees. If they do, this is called "balance billing" and this is prohibited.
Your out-of-pocket costs can be lower when you visit an in-network dentist. This is because PPO plans typically base coverage on a percentage of the cost of treatment you receive. Since in-network dentists have agreed to charge less, you pay less. Some PPO dental plans further incentivize members to seek care from in-network dentists by reducing the plan coverage for treatment received from out-of-network dentists.
Plan members can realize a greater sense of confidence in the qualifications and reliability of in-network dentists because in-network dentists undergo a safety and quality review process known as credentialing. Your plan reviews a variety of data sources to ensure that the dentist meets important quality standards. This includes a review of the dentist's license and specialty certifications, liability coverage, malpractice history, billing patterns, and treatment quality outcomes. This process is typically repeated every two or three years.
Exclusive Provider Organization (EPO) plans work similarly to PPO plans, but require that you seek care from in-network dentists only. These plans do not provide coverage for treatment from out-of-network dentists. Since EPO networks are more limited than PPO networks, your dental benefits may be more robust resulting in stronger dental coverage levels and greater savings.
Similar to PPO dental plans, dentists who participate in an EPO undergo safety and quality review for credentialing.
Government-sponsored plans such as Medicaid and Children's Health Insurance Plans (CHIP) such as Michigan's Healthy Kids Dental program, are available to those who qualify based on their financial situation or disability status. There are also privately offered plans like Medicare Advantage plans to which you may have access depending on your age or other factors. State or federal plan administrators can provide more information on how to access these types of plans.
Dentist membership plans provide dental coverage to patients of a specific dental practice. Because the dentists directly offer these plans themselves, any dental services you receive from other dentists may be ineligible for reimbursement. It is important to consider that these plans lack oversight from a plan administrator or third party who monitors dentist treatment and billing patterns.
It is important to consider your options when you choose a dental plan. What is important to you may not be as important to someone else. Here are examples that you may want to consider before you select a dental plan.
Last updated: 12/9/2022
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