Have you ever wondered, “What does typical dental insurance coverage look like?” This question is being asked more frequently with the Affordable Care Act’s inclusion of pediatric oral-health benefits as one of the 10 essential-health-benefits categories.
As details of the ACA are clarified, the phrase “typical employer policy” is being used to describe what benefits should be covered. The ACA’s involvement makes this a good time to describe what “typical” dental-insurance coverage looks like to Delta Dental.
In order to define typical dental coverage, it’s important to understand the different types of dental coverage. Dental coverage is usually defined by network structure, and commonly falls into one of three categories: Dental Health Maintenance Organizations (DHMOs), Dental Exclusive Provider Organizations (DEPOs, usually shortened to EPOs), and Dental Preferred Provider Organizations (DPPOs, usually shortened to PPOs).
DHMOs and EPOs require members to use in-network dentists to receive a benefit. DHMOs make members pick one primary-care in-network dentist, while DEPOs let members use any in-network dentist. PPO members don’t have to see network dentists, though benefits can be better if they do. PPO designs can have the same benefits in- or out-of-network (passive PPO), or richer benefits for members who choose network dentists (traditional PPO).
The passive PPO is a very common design, making it an ideal foundation for defining typical dental coverage.
PPO designs typically include three elements related to paying for the cost of care: deductible, annual maximum, and coinsurance.
The deductible is the amount of dental expenses that the member pays before the policy pays toward the cost of care. Deductibles are typically annual, but “annual” could refer to calendar-year or policy-year. There is no “typical” definition of “annual” in dental insurance.
It’s common for dental plan designs to waive the deductible on preventive services. This means the dental policy will cover its share of preventive costs regardless of whether the member has paid the annual deductible.
The most common deductible is $50 for an individual, with a maximum of three times the individual deductible for family coverage.
The annual maximum is the maximum dollar amount that the dental policy will be pay out over a 12-month period. Similar to the deductible “year”, the annual-maximum “year” can be a calendar year or policy year. The most common annual maximum is $1,000.
Coinsurance refers to how much of a given claim is covered by the dental policy after the deductible (if applicable) is paid, subject to the annual maximum limit. Coinsurance amounts are typically presented as the percentage paid by the dental plan. For example, with 100% coinsurance, the procedure is covered in full by the dental policy after the deductible is satisfied, subject to the annual maximum.
Dental benefits are typically subdivided into preventive, basic, and major services. Each category can have a different coinsurance level, and the services in each category can vary from policy to policy. The most common dental plan design has 100% coinsurance for preventive services (like cleanings and X-rays), 80% for basic services (like fillings), and 50% for major services (like crowns).
The last remaining piece of the coverage puzzle is orthodontia. Orthodontia benefits for children and/or adults usually have coinsurance and a lifetime maximum, meaning the amount paid by the policy is limited over the time coverage is in effect and does not reset.
Orthodontia is found in about half of all dental plans. If the plan does cover orthodontia, the most common design is child-only orthodontia with 50% coinsurance and a lifetime maximum of either $1,000 or $1,500.
So, there it is: To Delta Dental, typical dental coverage is:
- a passive PPO
- with a $50 individual/$150 family deductible
- and a $1,000 annual maximum
that covers:
- preventive services at 100%,
- basic services at 80%
- and major services at 50%.
If orthodontia is covered, it will likely be child-only coverage with 50% coinsurance and either a $1,000 or $1,500 lifetime maximum.
