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Dental insurance comes in the same varieties as health insurance. Indemnity (fee-for-service) plans, Managed care plans, a PPO type plan. However, the philosophy on which dental insurance was created is somewhat different than health coverage for the rest of your body and so is the coverage.

In general, dental insurance covers four areas. How benefits are accessed differs among the various types of plans. 

Whether treatments need to be pre-authorized, and whether you will have to deal with bills and additional payments, depends on the type of plan.

If you get dental insurance from an employer, a Summary Plan Description will describe the basic features. If you leave work, you have the right to continue dental coverage under COBRA.

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Differences Between Dental Insurance Philosophy And The Philosophy Underlying Health Insurance

Survivorship A to Z generally avoids getting too deeply into philosophy and focuses on practical assistance. However, it will help you understand how dental benefit schedules are set up if you understand that the philosophy behind dental coverage is very different from health insurance.

Minor health problems usually go away on their own. That is why most indemnity health plans have deductibles and co-insurance to discourage an insured from using the health plan for every sniffle and sneeze.

Dental care is just the opposite. A dental problem never heals itself. In fact, left untreated, it generally gets worse. A soft spot on a tooth surface will become a cavity which will eventually destroy the tooth and infect neighboring teeth. Because of this, dental insurance has always emphasized regular preventive care, even more strongly than medical HMOs.

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Health Insurance: HMOs

Benefits Covered By Dental Insurance

Dental care is divided into four areas for insurance purposes:

Preventive:  The work that needs to be done to keep teeth healthy - including regular check-ups, cleanings, and x-rays.

Restorative (sometimes called Basic Services):  These are procedures, such as fillings, root canals, and other similar procedures, that are used to restore a damaged tooth to good health.

Replacement (sometimes called Major Services):  These procedures are used when the tooth cannot be restored but must be replaced. This can be anything from a crown built over the base of the natural tooth to a complete set of dentures.

Orthodontia:  Braces to permanently move your teeth and all that they entail.

Benefits Under An Indemnity (fee-for-service) Dental Plan

Benefits are divided by the type of dental care. As a general rule, the earlier the treatment, the broader the benefits.

Preventive: The goal is to get people to have regular check-ups and cleanings so that there will be no need for more serious (read expensive) dental work. Because of this, most dental plans offer broad preventive benefits. Typically, there is no deductible, and 100% coverage for prophylaxis (cleanings), check-ups and x-rays. This coverage is usually limited to two cleanings and check-ups per year with x-rays limited to once every one or two years.

Restorative (or Basic): Restorative benefits usually have an annual deductible of $50 - $100 after which the plan pays a percentage (usually somewhere between 70% and 90%) of the "Usual, Customary & Reasonable" charges. (For a description of "usual, customary and reasonable, look at the discussion concerning health insurance by clicking here. The concept is the same.)

Replacement (or Major Services): Replacement benefits often share deductibles with Restorative charges, so if you've met the deductible for either service, the other is also covered. Replacement coverage co-insurance is generally different from the restorative percentage, frequently in the neighborhood of 50%. Occasionally there will be a one year waiting period before Major Services are covered.

Annual Maximum Benefit: Dental plans generally have a maximum annual benefit in the ball park of between $1,000 and $2,500. The maximum will apply to all charges.

Orthodontia: Orthodontia is often excluded from dental coverage. When it is offered, it is usually a small amount such as 50% of charges to a maximum of $500 or $1,000 per person.

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Benefits Under A Dental Managed Care Plan

Dental Managed Care Plans are sometimes called Dental Pre-Paid or Dental Maintenance Organization (DMO).

Under a Dental Managed Care Plan, you must receive all of your dental care from a dentist who contracts with the insurer. You choose from the company's list of participating dentists.

However, rather than pay a flat co-pay such as $10.00 per visit as you would with a health insurance plan no matter what the visit is about, with dental insurance you pay a co-pay based on the procedure that you have performed.

There is often a very small or no co-pay at all for preventive care while you may pay $10 or $25 per filling. On more expensive procedures like crowns, bridges and dentures, you may have to pay $100, $200 or more, but you will still pay far less than the actual cost of the procedures. Sometimes, these plans will impose a one year waiting period on Major Services.

If covered at all, you will probably have to pay at least half or more of the actual charge for orthodontia.

The plan document will provide a long list of dental procedures and what you are expected to pay for each one.

There is usually no annual maximum benefit.

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Health Insurance: HMOs

Benefits Under A PPO Dental Plan

A PPO Dental Plan can be similar to a medical PPO with the plan paying higher percentages for using contracting dentists than it does for services of dentists who are not part of the PPO's network. Most dental plans like this are more like a Point of Service Health Plan where you pay a co-pay if you see a contracting dentist, and a deductible and co-insurance if you see non-contracting dentists.

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Health Insurance: PPO

Summary Plan Description

Dental plans provided by employers are considered Employee Welfare Benefit Plans so are covered under the federal ERISA statutes. For practical purposes, this means that employers are required to provide you with a complete description of the plan benefits in the form of a Summary Plan Description. Request one if you do not receive it initially. See ERISA for sample letters requesting a Summary Plan Description.