Dental Insurance (Benefit Plans)

About Dental Plans in Wisconsin and what to Consider

Dental insurance (often referred to as a benefit plan) is not required to see a dentist.

Patients should carefully review the cost of a dental insurance plan before purchasing. Compare the average annual cost of a household’s dental bills with the proposed annual expenditure (12 monthly premium payments). It may make more financial sense to pay out-of-pocket for dental care than to pay a monthly premium for a plan that has a spending cap and coverage limitations.

Dental offices help patients make their oral health a priority with treatment plans and payment options: Cash, check, debit card, personal credit card, patient credit agreements, third-party financing plans and/or installments (usually reserved for long-term patients who dentists know well).


What to look for

When deciding if a dental insurance (benefit) plan is the best choice for you, your family or your organization, consider:

Affordability: The cost of dental treatment increased just 2.3 percent from 2010 to 2012 or less than the cost of all consumer goods (2.6 percent), medical care (3.5 percent), hospital services (5.2 percent), prescription drugs (3.9 percent) and physician services (2.4 percent) according to the U. S. Bureau of Labor Statistics.

Prevention: The vast majority of dental diseases are infectious, irreversible and destructive. They can only be successfully diagnosed and treated by a licensed doctor of dental surgery (DDS) or dental medicine (DMD) with support from a qualified dental staff. Regular exams, X-rays and preventive care (e.g., cleanings, fluoride, sealants, early treatment of decay) protect against advanced dental disease, saving individuals pain, dollars and time in the dental chair over the long term. The “Burden of Oral Disease in Wisconsin – 2010” report notes there’s still work to be done with 20 percent of Wisconsin’s third graders having untreated decay. Twenty-five percent of Wisconsin adults ages 35 – 44 have lost a tooth to decay.

Cost-effectiveness: Dental decay or disease that is detected early costs less in terms of treatment dollars and time in the dental chair. For example, the American Dental Association notes in its “Action for Dental Health: Bringing Disease Prevention into Communities” that the national average cost to apply a sealant and help seal out decay in a primary (baby) or permanent (adult) tooth is $44.12, compared to $146.61 for an amalgam (“silver”) filling, two-surface, in a permanent tooth.

Predictability: Although the need for dental care varies greatly among individuals, the dental needs of an employee group are highly predictable. For this reason, dental insurance or benefits can be self-funded. The risk of wide fluctuations in cost and utilization, evident under many medical coverages, is rarely observed with dental statistics.

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Types of plans

In network

Traditionally, dental insurance (benefit plans) permit patients to receive treatment from a licensed dentist of their choice. However, payment for care provided may vary depending on whether or not that dentist is a contracted provider with that specific plan. If a dentist is not a contracted provider, the patient is usually expected to pay the difference between what the plan pays and the dentist’s normal fee. If a dentist is a contracted provider, he/she has agreed to absorb a plan’s discounted fee as payment for services covered by the plan and does not charge the patient the difference between his/her normal fee and that set by the benefit company. Note some services will require a copayment/coinsurance from the patient.

Closed panel

Closed panel plans basically tell participants that for any dental services to be reimbursed, they must be provided by a dentist under contract with the plan. If a beneficiary decides to go to a dentist of his/her choice but is not under the plan’s contract, then that patient receives no payment or benefit coverage for services received and is responsible for paying the entire amount out of pocket. There has been an increase in closed panel plans in recent years.

Self-funded (employer-funded)

With great success, both large and small employers have implemented self-funded plans (sometimes referred to as direct reimbursement programs) to assist employees in meeting their dental care costs. These programs are self-funded by the employer rather than paying an insurance company to assume the plan’s risk. For example, an employer might agree to pay 80 percent of up to $1,000 a year for dental care for each employee.

A lower-cost, third-party administrator operates the plan which saves employers the expense of having an insurance company design, market and/or administer a dental plan. Benefits are set at an annual maximum dollar limit or percentage thereof, rather than controlling costs through a cumbersome list of covered services and limitations. These plans incorporate patient responsibility by having individuals pay for a portion of the services they receive, thus engaging them in their dental care.

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Services

Ideal dental insurance (benefit) plans have three categories of treatment.

Preventive, diagnostic and emergency services

Preventive dentistry refers to dental procedures that prevent the occurrence of oral disease, such as cleanings. Diagnostic services, such as X-rays, detect the presence or absence of disease. Both preventive and diagnostic services are vital to an individual’s oral wellness and should be considered an integral part of any company’s program. By providing access to these services, employers can realize long-term cost containment. Services include oral examinations, cleanings, X-rays, fluoride applications, sealants and space maintainers. The ADA and WDA recommend this category of treatment be covered 100 percent and not apply deductibles or copayments. Coverage for this treatment category is frequently in the 100 percent payment range.

Basic restorative dental care: Restorative dental care covers a range of treatments, because these needs will vary considerably for employees in any company. A dental benefits plan should include restorations (e.g., fillings), oral surgery, periodontal treatment and root canal therapy. Coverage for this category of treatment is frequently at 80 percent.

Major restorative dental care: Major dental care generally involves more extensive procedures, such as crowns, dentures, bridges and orthodontics. Coverage for this category of treatment is frequently in the 50 percent payment range.

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Your family’s needs

In addition to the three categories of treatment included in an ideal dental insurance (benefit) plan, there should be patient participation in the payment of some services through copayments or coinsurance. Personal responsibility for assisting with payments helps patients value the care and benefits provided.

Most dental plans are designed to be of “assistance” in paying for dental services, especially regular, preventive care. They do not pay 100 percent of all procedures needed.

When choosing dental coverage, consider:

  • Will you or your children have to change dentists?
  • Can you choose the dentist you want to see for your oral health care?
  • If you have to choose a dentist from a list of providers, where is the practice located and how far you will have to travel?
  • What is the monthly insurance premium cost?
  • How much does the plan cover for preventive, basic and major dental treatment needs?
  • Are there any waiting periods before the plan covers certain care?
  • Does the plan allow freedom to choose a specialist?
  • Does the plan cover orthodontics?
  • What insurance (benefit) plans do friends and neighbors use?

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Dental checklist for patients and health law navigators

The Health Insurance Marketplace offers plans to help pay the costs of going to a dentist. The Affordable Care Act or ACA requires the marketplaces to offer dental plans for children; Wisconsin also offers dental coverage for adults.

These questions can help you review your dental insurance options:

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Poor oral health affects job performance

Poor oral health among adults contributes to an estimated 164 million lost work hours every year in the United States according to the U.S. Surgeon General. (More than 53 million school hours are lost annually to dental-related problems by children in this country.)

Dental disease does not go away and only gets worse without proper care. Professional intervention by a dentist is necessary to halt the decay or disease process. Treating problems early and before they require extensive and expensive attention saves money. For example, a small cavity left untreated becomes a bigger cavity that requires a large filling that could cost two or three times more.

A large cavity left untreated could lead to a root canal, crown and/or extraction. Either way, the employee loses work, because root canals and/or crowns require several visits to the dentist. If the tooth is pulled, the employee must decide about a costly replacement (e.g., implant, bridge).

Regular exams, X-rays and preventive care protect against advanced dental disease, saving individuals pain, dollars and time in the dental chair over the long term.

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Why employers should offer dental benefits

  • Dental treatment is relatively low cost. It makes economic sense to provide a dental benefit package.
  • Dental insurance benefits help individuals by paying for a portion of the care cost.
  • Employee absences or poor work performance may be attributed to poor dental health. According to the National Center for Health Statistics, each year, dental disease causes one in 10 individuals to experience a restricted day, day in bed or lost work day.
  • A dental insurance plan can help recruit and retain employees. Dental coverage has been ranked one of the top five benefits weighed by employees considering job offers.
  • Dental benefits enhance a collective bargaining package.
  • A variety of dental insurance plans give purchasers more options and a range of benefit levels.
  • A dental insurance benefit promotes oral health by improving access to dental care for millions of Americans.

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Contact information

For more information on dental insurance (benefit) plans for individuals, families and companies, contact:

Professional Insurance Programs
6737 W. Washington St., Ste. 2360
West Allis, WI 53214
Phone: 414-755-4175
Email: info@insuranceformembers.net
Website: http://www.insuranceformembers.com/

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WDA