Q&A: Top 3 Dental Health Plans Questions Asked By Administrators

1. What is max coverage for a dental plan?

Most dental plans have an annual dollar maximum (max coverage). Max coverage is the most your insurance company will pay for dental costs incurred during your plan year.

Example

If you have a root canal for $750 and your dental plan covers 90% of the cost, your insurance company will pay $675, and you’ll pay $75 out of pocket. If your max coverage were $900, you’d only have $225 of remaining coverage because your insurance company already paid out $675 this year.

2. What is the average cost of dental insurance?

The cost of dental insurance varies considerably based on the number of employees, coverage, and location. Though, an average cost that a smaller employer in California would pay to provide dental insurance ranges from $20 and $50 per person per month. The employer can contribute towards the premium to lower employee costs and encourage higher enrollment. So employer and employee costs would vary based on that.

The National Association of Dental Plans (NADP) reports that roughly 50 percent of employers of all sizes offer dental benefits.

Typical Coverage

Those costs apply to the most common type of dental insurance, which is referred to as “100-80-50” Dental PPO style plan – this means that the plan covers up to 100 percent of fees for cleanings and normal preventive care. It usually covers up to 80 percent of the costs for Basic Services” which includes restorative care like fillings and simple procedures. Beyond that, only up to 50 percent of dental fees are normally covered for Major Services” including procedures like crowns and reconstructive bridges.

The American Dental Association estimates that those without any dental coverage are paying approximately $370 per year out-of-pocket for annual exams, cleanings, and X-rays. So having employer-sponsored dental insurance can save employees a lot of money.

Dental Plan Options

For employers, offering dental insurance is a good option if they want to attract top talent. Employers do not have to completely cover the premium costs of the dental plans. An employer can lower their costs by only contributing a certain percentage to the premium costs of certain plans thus giving employees options to opt-in or not. Employers can also offer plans where employees pay full costs but the company gets better rates by administering the plan and taking care of employee payroll deductions.

How to Find More Information

With such a wide variation between different circumstances, the best way to get information about average dental insurance costs for your organization is to contact an insurance broker, such as one at Zenefits.

3. Can an employee use dental insurance for restorative care?

Yes, most dental plans cover some types of restorative care to some degree. Restorative dental care includes everything that has to happen if preventative care breaks down. It ranges from basic work like fillings to major work like bridges. The types of restorative work covered and the cost depend on whether the procedures are considered basic or major restorative. Most dental plans break out dental work into four basic groups of dental care procedures:

Diagnostic and Preventive Care:

This includes cleanings, a limited number of exams during the year and sometimes x-rays.

Basic Restorative Care Vs Major Restorative Care

Many plans cover 70 percent to 80 percent of routine restorative care, which could include amalgams, smaller composite resin or stainless steel fillings for cavities.

However, restorative care can also involve major work and these types of procedures are often covered at 50 percent or less of the total cost. Examples of major restorative care could include major fillings, gold restorations, bridges, dentures and individual crowns. Coverage for major work may be limited by the number of procedures and/or a dollar amount per year.

Orthodontia:

Coverage for large dental reconstructive works, including braces, are often restricted to patients under 19 years-old. Many plans do not provide any coverage for orthodontia at all.

Conclusion

All dental coverage providers are required by law to give plan members an informational handbook that covers which kind of restorative care is covered at which level. If you have questions about types of coverages, exclusions or cost approximations, check you plan handbook or request a new copy. For example, in California, you can find helpful general information and advice about dental plans in the California Dental Association’s guide to consumer protection laws, and each state has their own oversight agency. You can find guidance for your own state regulations by visiting this list of state dental associations.

Helpful Links:

Dental Plans – Basic consumer information about terms and dental plans.

ADA – The American Dental Association’s report on preventative and restorative care.

CDA – The California Dental Association’s consumer guide to choosing dental plans.

State Dental Orgs — A list of dental associations for every US state from the American Student Dental Association.