All dental plans are not created equal and comparing dental plan coverage can be overwhelming. Some differences between plans can be easy to identify: annual maximums, deductibles and co-insurance, for example, are fairly straightforward. As the old adage goes, the devil is in the details.
Here are 6 often overlooked details to look at when comparing dental plan coverage:
Frequencies & Limitations
Most dental plans have limitations, such as the number of times you can receive a cleaning each year. These are often based on frequency intervals (how often you can get a specific treatment and/or how much time must pass before you can get the treatment again). For example: Plan A covers dental cleanings twice a year, but cleanings must be at least 6 months apart. Plan B covers dental cleanings twice a year and cleanings can occur at any time within that timeframe.
Dental procedures with limitations may include cleanings/exams, X-rays, fillings, crowns and more. Limitations are typically based on standard of care guidelines from the American Dental Association, but longer or shorter frequency limitations can affect the cost of a dental plan. Delta Dental of Arizona offers generous frequency limitations while keeping plan costs affordable. This gives members greater flexibility to get the dental care they need when they need it. For example, a dental crown lasts 5-15 years on average. Many carriers standardly quote a 10-year frequency limitation on crowns. Delta Dental of Arizona standardly quotes 5-7 years for crown replacement on group dental plans and most individual dental plans. We understand that due to unforeseeable circumstances, members may need a crown replaced sooner than 10 years.
Under many dental plans, coverage for some services could be subject to a benefit waiting period. A benefit waiting period is the amount of time you must be on the dental plan before the carrier will pay for certain dental treatments. For example, some plans may require a 6-month waiting period for major services, such as crowns or dentures. Delta Dental of Arizona’s group plans typically have no waiting periods for preventive, basic or major services. We also offer individual plans with no waiting periods on preventive, basic or major services.
Benefit Categories & Coverage
Most dental plans divide covered services into different categories. Each category may have a different coinsurance level. For example, procedures in the diagnostic and preventive category may be covered at 100%, procedures in the basic category may be covered at 80% and procedures in the major category may be covered at 50%. Exactly which procedures are in each category can vary by plan and may affect the cost of the plan.
If you’re comparing dental plan coverage, it’s a good idea to check whether certain procedures are in different categories. If Plan A covers crowns as a basic benefit and Plan B covers crowns as a major benefit, you’re not comparing identical plans—even if all other aspects of the plans are the same.
Dental sealants are a clear protective coating for your teeth that can reduce the risk of cavities. Coverage for sealants can vary by plan, but many plans include sealant coverage up to age 16 on molars every 3 years.
Because of our focus on the importance of preventive care, Delta Dental of Arizona offers expanded sealant coverage on group plans. Our standard sealant coverage is up to age 19 on molars and bicuspids every 3 years. This allows members ages 16-19 to have sealants on 8 extra teeth.
The size of the network can vary by plan. Generally, you’ll want a large network of dentists. The larger the network, the more likely it is that your favorite dentist is in-network. In addition, larger networks typically mean better utilization rates—and network utilization is the biggest way to control claims costs. (Related: Tips for Comparing Network Size.)
Keep in mind that the size of the network isn’t the only measurement of network strength. You’ll also want to find out how the carrier works with network dentists and what safeguards are in place to protect members. Delta Dental of Arizona network dentists go through an extensive credentialing process. In addition, our professional relations team is dedicated to educating network dentists on plan designs, proper claims submission, opioid abuse and other industry topics. Our staff also conducts audits at each dental office at least once every 3 years to make sure claims are submitted correctly and our members are being charged the right amount for services. In the last 3 years, our fraud and abuse controls have resulted in more than $177,200 in dental office overcharges paid back to patients.1
Missing Tooth Clause
It’s common for someone to be missing a tooth. Among adults 35-44 years old, 69% have lost at least 1 permanent tooth. Many dental policies will have a missing tooth clause, meaning that if a tooth was lost before the dental policy was purchased, the dental insurer will not cover the tooth replacement (bridge or implant). Policyholders often do not know this clause exists until it is too late.
Delta Dental of Arizona does not believe members should be penalized because they are missing a tooth. As a standard, our group and individual dental plans do not limit benefits due to a pre-existing condition, such as a missing tooth.
Whether you’re shopping for dental insurance for yourself, your family or your company, we hope this information will help you choose the best plan option for your needs. However, if you have more questions, we’re happy to help.
Note: This article references Delta Dental of Arizona’s standard policies. Your dental policy may deviate from the standard. Always refer to your plan booklet for full coverage specifics.
1Delta Dental of Arizona internal data, 2016-2018