Health insurance typically does not cover dental care; however, in an emergency or if oral surgery is required it could be covered under health plans.
The Affordable Care Act does not mandate dental benefits as part of marketplace plans; however, that does not preclude them from doing so and many standalone dental policies on the market do indeed include them.
What is dental insurance?
Dental insurance is a form of health coverage designed to cover dental expenses. This coverage may come through your employer-sponsored plan or can be purchased independently from an insurer.
Dental policies typically contain deductibles, copayments and coinsurance that must be met in full before insurance will cover your costs. They typically set annual spending maximums as well as waiting periods before covering more expensive procedures like crowns.
Some insurance companies also offer discount plans, which partner with participating dentists to offer discounted dental fees. Although these plans don’t fall under traditional PPO or DHMO plans, they can often prove more cost-effective solutions.
HMOs are a type of health insurance plan that requires members to select a primary care doctor or medical group as the “gatekeeper”, who oversees your access to care and refers you if any specialist visits become necessary.
HMO plans may provide utilization review or case management to their members, which involves monitoring overall health status, identifying specific problems and assigning a case manager to help you address these concerns.
HMOs offer multiple advantages, including reduced costs and access to a broad selection of services; however, these plans do have their share of drawbacks.
Preferred Provider Organizations, or PPOs, are health insurance plans that give you more freedom and flexibility in choosing where and when you receive care. Similar to an HMO plan, however, PPOs don’t mandate using doctors and hospitals within its network of providers.
PPO plans differ from other insurance plans in that you can visit doctors, hospitals and healthcare providers outside your plan’s network at any time without first getting permission from your primary care doctor (PCP). However, you will typically pay more out-of-pocket for these services that fall outside your plan’s network.
Indemnity plans are fee-for-service dental insurance models that don’t bind you to one dentist; thus allowing you to select any dentist of your choice.
Additionally, indemnity plans don’t require patients to obtain a referral before seeing specialists – an advantage for patients who don’t want their insurance company telling them whom or whom not to see.
Indemnity plans provide tiered reimbursement based on what an insurer considers “usual, customary and reasonable” fees according to the American Dental Association. While this may help pay for preventative services at reduced prices, it may make saving on more serious services like root canals or oral surgery more challenging.
Reimbursement refers to the process by which dentists submit claims to insurance companies for payment, typically using dental software or their own computer system.
While most patients possess some form of health insurance, it may not cover all their dental care expenses. Many dental plans also impose annual maximums which limit what coverage can be paid out each year.
Medicare Advantage plans (Medicare Part C) sometimes offer dental benefits, although typically not to the same extent as Original Medicare.
Employers increasingly provide direct reimbursement programs referred to as Usual, Customary and Reasonable plans – or UCR plans – which go beyond traditional dental plans.