Dental Insurance Plans

Dental Insurance Plans

To continue from the earlier post on dental insurance plans...

1. Third Parties

Regardless of the dental benefits plan, there are usually three parties involved: you, the patient; the dentist providing care; and a third party with whom you or your employer contracts for coverage. If your options include a plan funded by your employer, you may have an administrator responsible for processing and payment of claims. The primary responsibility of the third party is to provide the financial foundation for your dental benefits plan. There are three types of third parties.

Dental Service Corporations.

These not-for-profit organizations negotiate and administer contracts for dental care to individuals or specific groups of patients. Delta Dental Plans and Blue Cross/Blue Shield Plans are examples of this third party type.
Insurance Carriers. These for-profit companies underwrite the financial risk of, and process payment claims for, dental services. Carriers contract with individuals or patient groups to offer a variety of dental benefits packages, often including both fee-for-service and managed car plans.
Self-Funded Insurers. These companies use their own funds to underwrite the expense of providing dental care to their employees. The company pays for the dental costs of its employees, usually with limitations on services and fixed-dollar allocations.

2. Choosing A Dentist
Dental benefits plans can be categorized by the options offered for selecting a dentist. Some plans allow you the freedom to choose your own dentist, while others, in exchange for lower rates, limit your choice. These two alternatives are called open and closed panel plans.

Open Panel. This type of dental benefits plan allows covered patients to receive care from any dentist and allows any dentist to participate. Any dentist may accept or refuse to treat patients enrolled in the plan. Open panel plans often are described as Freedom of Choice plans.

Closed Panel. This type of plan allows covered patients to receive care only from dentist who have signed a contract of participation with the third party. The third party contracts with a certain percentage of dentist within a particular geographic area. There are two types of closed panel plans.

Preferred Provider Organization (PPO) -- This plan allows a particular group of patients to receive dental care from a defined panel of dentists. The participating dentist agrees to charge less than usual fees to this specific patient base, providing savings for the plan purchaser. If the patient chooses to see a dentist who is not designated as a "preferred provider," that patient may be required to pay a greater share of the fee-for-service.

Exclusive Provider Organization (EPO) -- This closed panel plan allows a particular group of patients to receive dental care only from participating dentists. Although there may be some exceptions for emergency and out-of-area care, if a patient decides to see a dentist who is not listed on the EPO panel, charges for service will not be covered by the plan. Because participating dentist are required to offer substantial fee reductions, many dentists elect not to participate in EPO-type plans. Under some benefits plans, participating dentists may be salaried employees of the EPO. An EPO contracts with a limited number of practitioners within a geographic area. Access to necessary specialized care can be restricted. The EPO also may limit the amount of services that a patient can receive in a given calendar year.

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The above is taken from the booklet "What Everyone Should Know About Selecting and Using Dental Benefits." A Consumer's Guide to Dental Insurance, published in the public interest by the California Dental Association.

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