Individual dental plans are purchased outside of an employer-sponsored plan and can be expensive. They may have limits on covered procedures and a maximum annual amount that the insurance company will pay for services. Most plans have a copay or “customary and reasonable” (UCR) fee limit, determining how much the patient pays for care. Preventive care is usually accessible to patients.
Coverage
Dental insurance, which can also cover a portion of other therapies, can help with preventive visits and treatment costs. Patients should consider the monthly premium, deductible, and copays before choosing a plan. They should also know the maximum annual limit, which indicates the total amount the insurer will pay in a year. This limit is significant for those who require extensive treatment. Most individual dental plans use a formula to determine coverage, which can vary from one carrier to the next. A plan’s table or schedule of allowances lists all covered procedures with a specific dollar amount assigned to each. A dentist’s fee is then compared to the allowed charge, and the difference is billed to the patient. Individual dental plans that do not have provider networks, such as a DPPO or DHMO, generally have lower fees than traditional indemnity or fee-for-service plans. These plans, however, may have a higher deductible and maximum annual benefit. Some patients prefer these plans because they allow them to see any dentist and have flexibility with their out-of-pocket costs.
Deductibles
Whether you have dental insurance through your employer or are looking for a private individual plan, it’s essential to understand how each type works. Typically, plans will have a monthly premium, coinsurance or deductible, and annual maximum coverage amount. The type of plan you choose depends on your personal needs and budget. Indemnity plans offer the flexibility to see any licensed dentist. In contrast, Preferred Provider Organization (PPO) and Dental Health Maintenance Organization (DHMO) plans list dentists who have agreed to accept the plan’s fees. The cheapest individual dental plans typically have lower monthly premiums but may not include an extensive provider network. This could be an issue if you already have a dentist you prefer to visit, but the plan only accepts them. Other things to consider are deductibles and annual maximum coverage amounts. These limitations can make a low-cost individual plan less appealing, especially if you’ll pay for procedures out of pocket. Some plans also have a Least Expensive Alternative Treatment (LEAT) clause, covering only the least expensive treatment for a given condition.
Copays
Individual dental plans come in various forms, including those that are part of Marketplace health coverage and separate standalone dental plans. The plan type you select will impact how much you pay for your care in terms of monthly premiums, copayments, or coinsurance. A copay is a fixed dollar amount you must pay for a visit, typically after you meet your deductible. Most insurance carriers also have a maximum annual benefit or “plan year maximum” that caps how much they will spend on your dental costs in a given calendar year. Dental Preferred Provider Organization (DPPO) plans have contracts with dentists to obtain a discount on overall fees, which are capped at the “usual, customary, reasonable” fee recognized by the insurer. In general, these are cheaper than indemnity plans and offer greater flexibility in the choice of dentist.
Network of Dentists
When purchasing individual dental insurance, you will want to ensure that the dentists in your network are a good fit for your oral health needs. Many plans offer a preferred provider organization (PPO), like a health insurance PPO, or a dental health maintenance organization (DHMO), which operates like a traditional HMO. With a PPO or DHMO plan, your out-of-pocket costs are usually less when you visit a dentist in your network than when visiting an out-of-network provider. Some dental plans limit the amount they will pay for a treatment during a year, known as the annual maximum. This is to help you avoid the costly overuse of dental services and to encourage you to find more cost-effective alternatives for treatment. A discount dental plan might be your best option if you have minimal dental care needs. These plans do not cover dental procedures but offer discounts on various oral health products and services. You can purchase a discount dental plan through an insurance broker or the provider.
Premiums
Individual dental plans offer a variety of options for all budgets. Some of the most popular include Preferred Provider Organization (PPO), Dental Health Maintenance Organization (DHMO), and Discount or Referral Plans. Each offers its own set of benefits and features. Many plans have a deductible that must be met before the insurance begins to pay. Some have coinsurance, a percentage of costs you and the plan share after meeting the deductible. Some have maximum annual benefit limits.