If you haven’t already heard about the rising number of ER visits for dental injuries or other emergencies across the U.S., do yourself a favor and look it up. No time for that? Here’s a quick summary:
According to an April 2015 report published by the American Dental Association, trips to the ER due to dental conditions nearly doubled between 2000 and 2010, and the number continues to rise. Overall, ER visits have gone down for those aged 19 to 25 and remained about the same for children. The increased number of visits is by people aged 25 and older.
However, as investigative reporters across the country have shown, few emergency rooms are equipped to deal fully with dental emergencies. In many, perhaps most cases, ER patients with dental concerns are treated with painkillers and antibiotics, and are then referred to a dentist.
What is behind the rising number of dental ER visits?
Many issues are likely to be fueling the continued rise in the number of people who go to the ER due to dental
conditions. For one, insurers have traditionally separated dental coverage from health coverage, an incongruity that carried over and now affects how health benefits are defined in the Affordable Care Act. Dental and vision coverage for children is defined as one of the 10 essential health benefits, but dental coverage for adults is not required.
Medicaid attempts to ensure older Americans have adequate access to dental care, but compared to adults with private health insurance, adults with Medicaid are nearly 5 times as likely to have poor oral health. (Source: National Center for Health Statistics, 2012.)
Another piece of the puzzle is the lack of access to dental professionals in some rural or remote parts of the U.S. In many parts of the nation, there is an uneven distribution of dentists, which is having serious consequences. Kaiser Health News reported in 2013 that 16% of Americans live in areas with an insufficient number of dentists.
Federal guidelines, according to Kaiser, call for one dentist to every 5,000 people. Those who live in under-represented areas cope with the lack of dentists as well as they can, often by putting off or doing without necessary dental care until a trip to the ER is unavoidable.
What is being done to address the problem?
The increase in dental emergency room visits is straining the limits of emergency departments and costing far more than routine care and prevention would have cost. For example, it is estimated that for every dollar spent on children’s preventive care, between $8 and $50 could be saved on emergency treatment. (Source: Insuring Bright Futures: Improving Access to Dental Care and Providing a Healthy Start for Children.)
Dental schools, dentists, community health centers with dental clinics, dental associations, and non-profit organizations are doing all they can to provide help for people who have no dental coverage or who have poor access to dental professionals. Hardly a month goes by without at least one major free dental event being held somewhere across the U.S., and many smaller events are being held frequently, as well.
In addition, support continues to build for dental therapists. Proponents of creating this new type of “mid-level” dental practitioner say dental therapists can help to increase access to oral health care and free up dentists to do other, more critical work.
What can you do? Prevention is Key
At a policy level, the rise in ER visits for dental complaints indicates a need for more spending on adult oral health education and programs that support preventive dentistry for at-risk populations. On an individual level, understanding this situation should encourage more individuals to focus on preventing oral health problems long before they get out of control.
People with dental insurance are twice as likely to see a dentist as are those without a dental plan. (Source: National Institute of Health, 2010.) The generally low cost of dental insurance makes it highly affordable compared to emergency care.
In addition, many people who purchase dental insurance can benefit immediately. That is because dental insurance encourages, and generally pays for, regular check-ups.
Here are some of the key reasons why dental coverage is important to have, and – arguably – among the health benefits that should be considered “essential.”
- To Help You Pay for Costly Care: Dental care can be simple – such as a twice-yearly visit for a professional cleaning and x-rays – or it may involve costly care, such as oral surgery, getting a full set of dentures, or needing a crown. Depending on the type of dental insurance you get, dental plans generally pay either all or a percentage of the charges.
- To Help You Maintain a Healthy Mouth: Studies have shown regular dental exams and dental cleanings help people keep their teeth and gums healthy. In fact, most insurance plans pay 100% for check-ups every 6 months because the insurers know prevention is the key to cost-control.
- To Help You Protect Your Overall Health: The artificial barrier between oral health and health, period, is an illusion. Studies show our mouths can exhibit the symptoms related to more than 120 different non-dental diseases. So, even if there’s nothing wrong with your teeth and gums, regular visits to the dentist can help ensure early detection of serious diseases such as diabetes and heart disease. And that alone can make dental insurance well worth the investment.
And if you are a woman, you have even more reason to take charge of your oral health. That’s because, year after year, the percentage of U.S. women in the 18 to 64 age group who miss needed dental care due to cost is consistently higher than it is for men. (Source: National Center for Health Statistics, 2013.)
Many types of dental plans can help you take charge or your oral health, including dental health maintenance organization plans (DHMOs), discount dental plans or cards, and preferred provider organization plans (PPOs). To receive instant online quotes for plans available in your area, enter your zip in the box on our home page.
Why Dental Insurance is Important: Learn more about the top three reasons why dental insurance makes sense.
Common Causes of a Broken Tooth: Learn what to do in case of a dental emergency as well as the situations that need attention right away.
Knocked-Out Tooth: Learn what you can do to help make sure a tooth survives if it is knocked out.
Teeth are having a good run at the Supreme Court this year. SCOTUS has handed down decisions in two cases involving oral health during 2015.
In one of those cases, decided at the end of February, the North Carolina State Board of Dental Examiners challenged a lawsuit brought by the FTC and lost. The suit alleged the board had violated antitrust laws by barring non-dentists from providing teeth whitening services at mall kiosks.
It’s nice to know the folks in North Carolina can now enjoy low-cost teeth whitening where they shop, but there’s some really great news for US kids.
Here it is: When SCOTUS ruled this month that the ACA’s premium tax credits were not just for those who used a state-based exchange, it also helped pave the way to good oral health and better access to dental care for children.
Pediatric Dental Health and the ACA
According to the CDC, while for the most part preventable, tooth decay is still the most common chronic disease among US kids. The ACA, though, still has a chance to turn that around thanks to the Court’s latest decision.
While the ACA – like the insurance industry in general – oddly cuts off oral health coverage from coverage for the rest of the body, it does require some dental coverage for some citizens. Dental insurance for adults is not required under the ACA, but subsidized health plans must address at least 10 types of health care, the essential health benefits (EHBs). These include oral and vision services for kids.
Including dental coverage for children in the ACA was a huge step in the right direction. With the Court’s new decision on consumers’ eligibility for tax credits, millions of children can continue to reap the benefits, including healthy, happy smiles.
Affordable Care and Your Oral Health
The ACA provides a number of ways to purchase dental coverage. Some states include oral care benefits for kids within the health plans available on their insurance exchanges. Others separate out dental coverage as standalone products.
States may also define oral care benefits for adults as part of the EHBs for their citizens. Some roll those benefits into the health plans they offer. Others offer them as standalone parts of the benefits package.
Greater Consumer Choice and Enrollment Availability
You can obtain private dental plans both on and off the government-run insurance exchanges. For broader plan selection and the ability to enroll in a plan at any time, many people turn to the private dental marketplace. People that recognize oral health is not really cut off from general health, often enroll in a separate, stand-alone dental plan after they enroll in marketplace coverage.
For example, DentalInsurance.com provides consumers across the US with access to a very wide selection of dental coverage options. These include traditional dental indemnity plans, dental health maintenance organization (DHMO) plans, preferred provider organization (PPOs) plans, and even discount dental plans or cards.
We’ve made it easy for you to find individual dental insurance, dental coverage for yourself plus one other person, or even dental coverage for your whole family. To compare dental plans available in your area, simply enter your zip in the box on our home page.
Hooray for SCOTUS and the ACA! Now, be sure to exercise your constitutional rights to life, liberty, and the pursuit of oral health!
Learn more about the ACA.
Dental PPOs (preferred provider organizations) are a type of dental plan that are very popular with both consumers and dentists. Nearly 3 out of 4 new dental insurance plans sold today is a PPO plan, according to dentaleconomics.com.
PPOs help you save money because the dentists who work with these types of plans agree to charge lower rates. It’s as simple as that!
…when you work with a dentist who participates in your PPO’s network (you’re not required to do so), you improve your ability to keep out-of-pocket costs under control
With a PPO, you know the maximum you will be charged for your dental work up front. In addition, when you work with a dentist who participates in your PPO’s network (you’re not required to do so), you improve your ability to keep out-of-pocket costs under control.
However, there are some limitations with PPOs. Not all types of work are available, and the amount of time your dentist can put into your work may also be limited. PPOs also include a calendar year maximum, a deductible, and waiting periods for some types of work.
Understanding dental PPO waiting periods
Waiting periods, or “wait times,” are one of the things many people just don’t “get” about dental PPO plans. This is simply the time that must pass between the day your plan begins and when you are eligible for some specific benefits.
Dental PPO waiting periods, if there are any, are outlined on the plan summary page at DentalInsurance.com. Here’s an example:
The plan summarized in this image has no waiting periods for preventive services. There is, however, a waiting period of 6 months for basic procedures and 12 months for major ones. This makes the plan one of the best selling dental PPO plans available from DentalInsurance.com.
More information about any plan is available by clicking the “Plan Features” link. In addition, various plans can be easily compared using the checkboxes at the top left of each plan summary.
Next: Compare dental insurance plans.
Some people think buying dental insurance also means having to get a new dentist. The truth is, it depends.There are many dental networks in the US, and using a dental plan that has a network doesn’t always mean you will lose freedom of choice.
There are 4 basic types of dental plans: indemnity plans, dental health maintenance organizations (DHMOs), preferred provider organizations (PPOs), and discount dental plans. All but one of these types makes special arrangements with specific dentists to perform services at better rates for their plan’s members.
Those contracted dentists make up each separate plan’s “dental network.” There are dozens – if not hundreds – of dental networks today in the US.
Learn more about four types of dental plans.
Whether you will be able to keep your current dentist depends on the type of plan you choose.
The range of freedom depends on your choice of plan
Most dental plans restrict which dentists you can go to for services. On the side of free choice, you can see any dentist when you have an indemnity plan. At the other end of the spectrum, DHMOs and discount dental plans require that you only use their network dentists.
Then, there are PPO plans, the middle ground in the spectrum of dentist choice. Similar to DHMO and discount plans, PPO plans are built around a dental network. With many PPO plans, however, the use of out-of-network dentists may be allowed.
Then, there are PPO plans, the middle ground in the spectrum of dentist choice…
Depending on the PPO plan, you may be able to see a dentist who is not a member of the network and still have some part of your expenses covered or offset by the plan. The best savings, though, will always go to members who use an “in-network” dentist.
So if you’re one of those people who loves your dentist and wants to continue seeing them (we hope you are!), check with them to find out what plans and networks they take part in. If you don’t have a dentist yet, think about the other criteria that may be important to you, and choose a dental plan accordingly.
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Need a little help getting the most out of your dental insurance? Along with this blog, check out our Dental Resources. You’ll find sections on Dental Insurance 101, Dental Insurance Terminology, Insurance Types, and loads of articles about dental and oral care topics.
The section on dental insurance terms can be a big help if you are new to dental insurance. After all, we hear about “benefits” every day, but when speaking of dental insurance, the term has a special meaning. Then there are terms like “indemnity,” “coinsurance,” and “UCR,” which you may have no idea how to define, whatever the context.
Dental Insurance lingo: A crash course
Nearly 500 terms are explained in our glossary. But you don’t have to read them all to get your bearings in the world of dental insurance.
To help you master a few of the basics, here are twenty of the most frequently used terms you’re likely to see if you’re in the market for dental insurance.
Administrator: One who manages or directs a dental benefit program on behalf of the program’s sponsor. (See Third-Party Administrator; Dental Benefit Organization.)
Benefit: The amount payable by a third party toward the cost of various covered dental services or the dental service or procedure covered by the plan. A related term, “Benefit Booklet” refers to a booklet or pamphlet which contains a general explanation of the benefits and related provisions of the dental benefit program.
Claim: A request for payment under a dental benefit plan or a statement listing services rendered, the dates of services, and itemization of costs. Includes a statement signed by the beneficiary and treating dentist that services have been rendered. The completed form serves as the basis for payment of benefits.
Coinsurance: A provision of a dental benefit program by which the beneficiary shares in the cost of covered services, generally on a percentage basis. A typical coinsurance arrangement is one in which the third party pays 80% of the allowed benefit of the covered dental service and the beneficiary pays the remainder of the charged fee. Percentages vary and may apply to table of allowance plans; usual, customary, and reasonable plans; and direct reimbursement programs.
Copayment: The Beneficiary’s share of the dentist’s fee after the benefit plan has paid.
Coverage: Benefits available to an individual covered under a dental benefit plan.
Deductible: The amount of dental expense for which the beneficiary is responsible before a third party will assume any liability for payment of benefits. Deductible may be an annual or one-time charge, and may vary in amount from program to program. (See Family Deductible.)
Dental Health Maintenance Organization (DHMO): Typically, the least expensive of dental plans. All dental services are provided by professional dentists who agree to provide specific treatments and services to patients at no charge (some services may require a co-payment.) DHMO plans reward participating dentists who keep patients in good health, thereby keeping plan costs low. Dentists are paid directly by the insurance company for each individual, regardless of how much or how often covered services are used.
Eligibility Date: Often referred to as “effective date,” this is the date an individual and/or dependents become eligible for benefits under a dental benefit contract.
Exclusions: Dental services not covered under a dental benefit program.
Indemnity Plans: Dental plans where a third-party payer provides payment of an amount for specific services, regardless of the actual charges made by the provider. Payment may be made either to enrollees or, by assignment, directly to dentists. Schedule of allowances, table of allowances, or reasonable and customary plans are examples of indemnity plans.
Limitations: Restrictive conditions stated in a dental benefit contract, such as age, length of time covered, and waiting periods, which affect an individual’s or group’s coverage. The contract may also exclude certain benefits or services, or it may limit the extent or conditions under which certain services are provided. (See exclusions.)
Maximum Benefit: The maximum dollar amount a program will pay toward the cost of dental care incurred by an individual or family in a specified period, usually a calendar year.
Patient: An individual who has established a professional relationship with a dentist for the delivery of dental health care. For matters relating to communication of information and consent this term includes the patient’s parent, caretaker, guardian, or other individual as appropriate under state law and the circumstances of the case.
Preferred Provider Organization (PPO): A formal agreement between a purchaser of a dental benefit program and a defined group of dentists for the delivery of dental services to a specific patient population, as an adjunct to a traditional plan, using discounted fees for cost savings.
Reimbursement: Payment made by a third party to a beneficiary or to a dentist on behalf of the beneficiary, toward repayment of expenses incurred for a service covered by the contractual arrangement.
Schedule of Benefits: A listing of the services for which payment will be made by a third-party payer, without specification of the amount to be paid.
Subscriber: The person, usually the employee, who represents the family unit in relation to the dental benefit program. This term is most commonly used by service corporation plans. Also known as: certificate holder, enrollee.
Usual, Customary and Reasonable (UCR): A dental benefit plan that determines benefits based on “Usual, Customary, and Reasonable” fee criteria.
Waiting Period: The period between employment or enrollment in a dental program and the date when a covered person becomes eligible for benefits.
Ready to become a dental insurance power user? Get familiar with the entire list of glossary terms.
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Need dental insurance? Zip-Based Search Reveals: Dental Plans in All 50 States
According to dentaleconomics.com, nearly 3 out of 4 new dental insurance plans sold today is a preferred provider organization (PPO) plan. This statistic alone speaks volumes about the desirability of PPO dental insurance.
But it isn’t just consumers who are eager to participate in PPO plans. Dentists are piling on the PPO bandwagon as well.
Like a health PPO, dental PPOs help patients keep costs under control while they help health care professionals connect with consumers more effectively. As a result, not only are more dentists contracting with dental PPOs – they are also contracting with a wider variety of PPOs.
In 2012, the average PPO dental provider had contracts with 8.4 PPO networks, compared with less than 6 networks each in 2008. Also, today the number of unique dentists in the average PPO network has grown to more than 72,000, an increase of nearly 9% over 2011.
Moreover, the average number of PPO provider access points (locations where a network dentist practices) also increased in 2012 from 2 to 2.25[i], and market penetration (the number of network dentists compared to the total number of dentists available) has increased as well.[ii]
Is PPO dental insurance right for you?
Clearly, a lot of consumers and dentists love their PPO networks. But is a dental PPO right for you? If you’re interested in participating in a PPO dental plan, here are a few things you should consider. First, choosing a PPO means you have the opportunity to reduce out-of-pocket costs by using an in-network provider.
Consumers who purchase a preferred provider organization (PPO) dental insurance plan must select a dentist from among the network of dentists participating in the PPO in order to be assured of the greatest savings. Some (not all) PPO dental plan providers allow patients the freedom to select an out-of-network dentist. However, patients who select an out-of-network dentist also have higher out of pocket costs.
If you already have a dentist that is not in the plan network, determine whether the higher out of pocket costs are substantial enough to entice you to change to a dentist that participates in a particular PPO dental plan. Equally important, examine in detail any restrictions on the types of treatment that participating PPO dentists are willing to provide.
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To learn more about PPO dental insurance or other types of dental insurance plans, visit our Online Resources.
[i] “Is Growth of Dental PPO Networks Sustainable?”
[ii] “As Dental PPO Penetration Increases, Is Market Saturation Near?”
“As a child,” the mush-mouthed comic Buddy Hackett used to say, “my family’s menu consisted of two choices: take it or leave it.” If you’ve ever shopped for dental insurance, you know that, fortunately, when it comes to dental coverage, there are many more options available.
To make the choice easier, it helps to compare and contrast the 4 basic types of coverage that are available for dental care. With that in mind, here’s a brief overview:
A dental health maintenance organization or DHMO (a type of “managed care”) is a network made up of highly qualified dentists who provide comprehensive and affordable care for individuals or families. Consumers choose a dentist from the network, and they pay a low monthly premium to receive services at either no cost or a reduced price (some services may require a copayment). The participating dentists receive fixed monthly fees.
DHMOs offer some great benefits. For example, they are normally the least expensive type of dental coverage, and subscribers have no waiting periods, deductibles, calendar year maximums, or claim forms. DHMOs are convenient for people who can’t wait for the waiting period on their indemnity plan or PPO to be satisfied. In addition, participating dentists may refer subscribers to dental specialists, and subscribers can receive a discount for specialty services from participating specialists. (Learn more about DHMOs.)
One of the most popular forms of dental insurance coverage is another type of managed care plan called a preferred provider organization (PPO). In this type of plan, consumers select a dentist from a network of preferred dental providers. The providers agree to provide dental care to members at reduced rates. PPO dental plan participants are assured of the maximum cost of their dental treatment in advance.
With a PPO, participating dentists have agreed to pre-negotiated fees. While the choice of dentists is somewhat limited, some PPO plans do provide the freedom to select an out-of-network dentist. In addition, after PPO members have used their maximum annual benefits, the costs for services still remain at pre-negotiated levels. (Learn more about PPOs.)
If being able to choose from the largest pool of dentists is high on your list of priorities, you may be interested in indemnity plans. Individuals with indemnity insurance are free to visit any dentist, unlike those with managed care plans. Subscribers to this type of coverage, also known as “traditional” insurance, pay their dentist’s bill in full and then submit a claim for reimbursement to the carrier.
If being able to choose from the largest pool of dentists is high on your list of priorities, you may be interested in indemnity plans.
Some key strengths of indemnity dental plans include the fact that indemnity plans typically cover a major part of the patient’s bill, and also that they help consumers plan ahead. Completing a pre-claim before having major services done lets consumers know up front what part of their bill the carrier will cover. (Learn more about indemnity plans.)
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Discount Dental Plans
Finally, while not “insurance,” discount dental plans (DDPs), also known as discount dental cards, are another type of coverage that can help consumers save on dental care costs. DDP members make monthly or annual payments in exchange for unlimited dental care services that are priced based on a discounted fee schedule. Services are provided by dentists who participate in the plan’s dental network.
Discount dental plans provide people who have no dental insurance with a cost-effective alternative. People can also use a DDP for services that are covered by one of the other types of insurance but unavailable due to a waiting period. Consumers can save up to 50% on dental work with a DDP compared to having no dental coverage. Moreover, the monthly or annual payments are usually a fraction of the cost people pay for other types of dental coverage. (Learn more about discount dental plans.)
Do you have questions about your dental insurance options? Learn more with the resources below, or leave a comment in the Reply section.
- Explore your dental coverage options and find answers to other questions about oral care in the Dental Resources section at DentalInsurance.com.
- Download a free dental insurance checklist designed to help you pinpoint the best dental plan for your needs.
- Dig into this infographic to learn more about the basic types of dental coverage available.