Insurance FAQ

A covered benefit refers to any dental treatment that is recommended by your dentist, included in your insurance plan’s fee schedule, and meets the criteria set forth by your insurance policy. These treatments are accepted under the terms of your group’s plan, meaning they are recognized as necessary and will be covered to the extent specified in your policy.

Optional treatment encompasses any dental services that are not included in your insurance plan’s fee schedule or exceed the basic requirements needed to restore a tooth to its original function. These treatments might include cosmetic procedures or advanced restorative work that goes beyond what your insurance policy considers necessary for functional dental health.

Indemnity or Traditional Insurance Plans: These plans operate on a reimbursement model, where the insurance company reimburses the member or the dentist at the dentist’s UCR (Usual, Customary, and Reasonable) fee. This model offers the flexibility to choose any dentist without restrictions to a specific network, providing a broader choice of dental care providers.

PPOs are among the most prevalent types of dental insurance. They offer a network of dentists who agree to charge reduced rates to plan members, thus potentially lowering your out-of-pocket costs. These plans usually cover a percentage of the cost for various types of treatment: preventive care (such as exams, x-rays, and basic cleanings) might be covered at 100%, basic procedures (like fillings) at 80%, and major procedures (such as crowns, bridges, and partials) at 50%. PPO plans often have an annual maximum benefit limit, which can vary from $1,000 to $2,000.

Designed to offer members basic dental care at the lowest possible cost, HMOs pay participating providers a fixed monthly amount for each patient assigned to their office. This capitation payment is meant to cover administrative costs and is typically quite low. Under an HMO plan, the patient is responsible for paying the dentist directly for services at reduced rates. Unlike PPOs and indemnity plans, HMOs usually have no annual maximum or deductible, but the choice of dentists is limited to those within the HMO network.

While not insurance in the traditional sense, these plans offer discounted rates on dental services from participating providers. Members pay an annual fee to join and, in return, receive discounts on various treatments. These plans can be a cost-effective solution for individuals without traditional dental insurance, offering savings on everything from cleanings and fillings to more significant procedures.