Understanding the Coverage of Family Dental Plans

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Shop for family dental plans on your own or find a Qualified Health Plan (QHP) that includes family dental coverage in your area. Use the tools below to filter by coverage type, costs, copayments, and deductibles.

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Every insurance plan has details, including what services are included or excluded and its annual maximum. Read your plan’s Evidence of Coverage carefully.

Fee-for-Service Plans

The insurance company lists fees for various procedures in these plans. When you visit a dentist, the insurer will pay for part of the procedure, but you will be responsible for the difference between the dentist’s fee and the insurance company’s set rate. These fees, also known as a “UCR” or “usual and customary” fee, are what insurance companies use to determine the maximum amount they will reimburse for each procedure.

These fee-for-service dental plans often feature lower monthly payments, known as premiums. These may be a good option for those who want to save money but still want access to quality dental care.

When choosing dental family insurance plans, consider your family’s current and future needs. Think about your past dental expenses and any potential future costs you can anticipate based on your family’s medical history. When comparing dental plans in the Marketplace, closely examine the premiums, copayments, and deductibles to help you decide which plan is right for your budget.

When you select a plan in the Marketplace, click “View plans and details” to view each one’s cost information, including deductibles, copayments, and premiums. You can shop for stand-alone family dental plans (select Adult & Family Dental Plan from the Dental Plan Type dropdown) or select a Qualified Health Plan that includes dental benefits (select Plans with Benefits that include family dental benefits from the QHP Selection dropdown). Both options will provide you with a wide range of coverage options.

Preferred Provider Organization (PPO) Plans

Similar to health insurance, dental plans come in a variety of options. Depending on the plan you choose will determine the out-of-pocket costs and how much coverage you have.

A Preferred Provider Organization (PPO) plan provides a network of dentists who have agreed to offer services to plan members at pre-determined fees. These fees are discounted from the usual and customary rates, making this plan popular for most people. With a PPO plan, you typically pay a fee, called a copay, for each service, and your provider will file your claim with the insurance company on your behalf.

These plans also allow you to see non-network dentists, but additional costs may be involved. The plan covers some extra costs up to a certain annual maximum. If you have a PPO plan, the portion of the maximum not used in one year can be rolled over and applied to future procedures.

Another type of dental plan is the Dental Health Maintenance Organization (DHMO). Like an HMO, this plan requires you to select a primary care dentist and only receive services from those in the DHMO network. This type of plan is best for cost-conscious people who are willing only to visit a specific group of dentists for their care.

Dental HMO (DHMO) Plans

Dental HMO (DHMO) plans are often a good option for people seeking budget-friendly coverage. These plans typically feature low premiums, minimal or no copayments for preventive visits, and a limited network of in-network dentists. They also offer an annual maximum that covers major procedures like fillings, crowns, and bridges.

If you need more specialized care, your primary care dentist will refer you to an in-network specialist. This is one of the critical differences between DHMO and PPO dental insurance plans. PPO dental insurance plans can provide more flexibility and a more extensive network of dentists but may come with additional costs in the form of deductibles or yearly maximums.

Choosing the right dental plan is about evaluating your priorities and deciding what coverage you need. Indemnity plans might be a good choice if you want the freedom to see any licensed dentist and don’t mind paying for out-of-network services. A DPPO plan might be better if you prioritize low out-of-pocket costs and prefer to stay within a provider network. A DHMO plan with a broader network of dentists might be best for those who want to balance cost-effectiveness and dentist choice. These factors are essential to consider when comparing dental plans for your family. You can find the options that meet your needs by assessing your specific situation and preferences in the Direct Benefits Marketplace.

Dental Management Organization (DMO) Plans

Unlike PPO plans, DMO plans typically offer a much more limited network of dentists. In exchange for a smaller selection of dentists, these plans offer lower costs to you as the consumer. As Health Maintenance Organization (HMO) plans for health insurance, these dental plans connect you with a network of providers that guarantee benefits if you use one of their contracted dentists. Typically, these plans do not have annual maximums or deductibles.

For non-preventive services, like fillings, root canals, or extractions, you will share the cost of the service with your plan after meeting a deductible and paying the copay. These deductibles and copays are usually a percentage of the cost of the service.

While DHMOs do not have annual maximums, they require you to select a primary care dentist to coordinate your care with in-network specialists. This is different from a PPO, which only sometimes requires you to have a referral from your primary care dentist to see a specialist.

Also, unlike a PPO, a DPPO will often have a negotiated fee with your provider that you and the insurance company will agree on before the procedure occurs. This will be shown on your pre-treatment estimate. This will give you an idea of your total costs for a particular procedure.

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