Navigating Dental Insurance: A Guide To Making The Switch

If you're looking to change your dental insurance, there are a few things you should keep in mind. Firstly, it's important to understand the difference between “in-network” and “out-of-network” dentists. In-network dentists are on a pre-approved list of providers in your plan, while out-of-network dentists are not. Typically, you'll receive greater benefits by using an in-network dentist, but some plans may still cover out-of-network dentists. Secondly, you should review your current coverage and identify your specific needs. Ask yourself questions such as: can you choose your own dentist? What routine and major dental care will be covered? Will there be coverage for pre-existing conditions? Finally, consider your options carefully. You can either switch to a different plan offered by your employer during the open enrollment period or purchase your own separate dental plan.

Understanding in-network and out-of-network

When choosing a dental healthcare provider, it's important to understand the difference between in-network and out-of-network providers. This will help you avoid paying high out-of-pocket costs.

In-network dentists have a contractual agreement with insurance companies, making them "participating providers". This contract defines the patients they can treat, the claims reimbursement process, and the rate of their fees. The insurance company decides what types of procedures an in-network dentist can perform for patients covered under their plan. The insurance company can deny payment or require the dentist to downgrade the treatment if they deem it cosmetic or unnecessary. In-network providers agree to fees set by the insurance company, which are often lower than the actual value of the procedure. Due to this, in-network providers tend to see more patients to make up for the difference in costs.

Out-of-network dentists, on the other hand, refuse to allow insurance companies to dictate how they treat their patients. They are not bound by the restrictions that in-network dentists must follow and can use the best materials and techniques without worrying about insurance coverage. They can spend more time with their patients and provide a more personalised experience. However, out-of-network dentists may result in higher out-of-pocket costs for the patient. If you decide to visit an out-of-network dentist, you may pay more for services as they have not agreed to contracted fees with your insurance company. Your insurance plan may also require a larger deductible and coinsurance payment for out-of-network care.

It's important to note that insurance companies often use scare tactics to discourage consumers from choosing out-of-network providers, claiming they are "bad" or more expensive. However, this is not always the case, and it depends on your insurance plan and the specific treatment you need.

Ultimately, the decision to choose an in-network or out-of-network dentist depends on your priorities. If you value affordability and convenience, an in-network dentist may be preferable. If you prioritise personalised treatment and having more control over your dental care, an out-of-network dentist may be a better option.

Choosing a separate dental plan

Types of Dental Plans

Dental plans typically fall into three categories: indemnity plans, managed care plans (HMOs and PPOs), and discount plans. Indemnity plans offer the highest flexibility as they do not restrict you to a specific network of dentists. However, they may have lower coverage limits, and you will be responsible for paying the difference between the dentist's bill and the plan's reimbursement. Managed care plans, such as HMOs and PPOs, have pre-approved networks of dentists who offer discounted fees. Dental HMOs tend to be more restrictive and do not cover out-of-network care, while dental PPOs usually provide some coverage for out-of-network services. Discount plans are not insurance but provide discounted rates when you visit dentists within their network.

Coverage and Costs

Most dental insurance plans follow a 100-80-50 coverage structure. They typically cover 100% of preventive care, such as exams, X-rays, and cleanings. For basic procedures like fillings and root canals, they cover around 80%. For major procedures like crowns, bridges, and implants, they usually cover around 50%. Keep in mind that many plans have annual benefit caps, typically ranging from $1,000 to $2,000, so you may reach this limit if you require multiple major services. Additionally, some plans may consider implants and other procedures as "cosmetic" and not cover them at all.

Waiting Periods and Deductibles

Dental insurance plans often have waiting periods before certain benefits become available. For basic restorative services, you may need to wait up to six months, while for major services, the waiting period can be a year or more. Additionally, most plans have deductibles, which is the amount you need to pay out of pocket before the plan starts covering your expenses. For individuals, the deductible is typically $50 annually, while for a family, it may be around $150.

Choosing the Right Plan for You

When choosing a separate dental plan, consider your dental history and the level of care you expect to need. If you have a family, look for plans that cover orthodontic services and have reasonable limitations on the number of cleanings or check-ups per year. It is also essential to review the plan's network of dentists and ensure that your preferred dentist is included. Additionally, compare the monthly premiums, copayments, coinsurance, and annual limits to find a plan that fits within your budget.

Knowing when to expect changes to your dental coverage

Dental coverage changes are not uncommon. Companies often re-negotiate their contracts with insurance providers, which can lead to shifts in your dental coverage. These changes are typically presented to you and other covered individuals at the end of the plan year, usually during an annual open-enrollment period. This period often falls between November 1 and January 15.

During this time, your employer is required to provide comprehensive information about your new plan, including any modifications from the previous plan. It is important to thoroughly review the details of your new coverage during this open-enrollment period to ensure it aligns with your needs. If you find it unsatisfactory, you can explore other options and select a different plan before the open-enrollment period concludes.

However, if you miss the opportunity to make changes during the open-enrollment period, your coverage will remain unchanged for the rest of the year. You will have to wait until the next open-enrollment period to review and modify your dental insurance plan.

In some cases, changes to your dental coverage may occur outside of the standard open-enrollment period. Certain life events or changes in circumstances can trigger what is known as a Special Enrollment Period. Examples of qualifying life events include losing health coverage, moving to a new location, getting married, having or adopting a child, or experiencing a significant change in your household income.

If you undergo a qualifying life event, you typically have a window of 60 days from the date of the event to enrol in a new plan. However, it is essential to report the change as soon as possible to initiate the process. Reporting changes ensures that you receive the correct amount of savings for your insurance plan and helps determine your eligibility for switching plans.

Additionally, it is worth noting that changes to your dental coverage may also occur if you switch employers or if your current employer changes the insurance provider. These transitions can introduce waiting periods before you can access certain benefits or services. Understanding these waiting periods and their potential impact on your coverage is crucial when navigating changes to your dental insurance.

What to do if your employer changes your dental insurance plan

If your employer changes your dental insurance plan, the first thing to do is find out what's new and what's different about the plan. This usually happens at the end of the year during an open-enrollment period. At this time, your employer should provide you with information on the changes. It's important to read the fine print so you know all the details. If you miss the open-enrollment period, your coverage will be set for the year, and you will have to wait until the next one to make changes.

During the open-enrollment period, it's a good idea to ask yourself a series of questions to determine if the new plan meets your needs. The American Dental Association (ADA) suggests asking:

• Can you choose your own dentist, or do you have to pick from a predetermined list?
• Can you stay with your current dentist, or will you have to change?
• What routine and major dental care will be covered (e.g. cleanings, x-rays, surgery, orthodontics)?
• Will you be covered if you need to see a specialist?
• Will a pre-existing condition prevent you from getting dental care paid for by the insurance company?

If the new insurance documentation doesn't clearly answer these questions, don't hesitate to speak to your employer. It's also important to understand the difference between "in-network" and "out-of-network" when it comes to dental care. "In-network" means a dentist is on a pre-approved list of providers in your plan, while "out-of-network" means they are not. You will usually receive greater benefits by using an in-network dentist, but it's important to check if your plan covers visits to out-of-network dentists and, if so, how.

If you're not happy with your employer's new dental insurance plan, you have options. You may find it's more affordable to pay out-of-pocket or purchase your own dental plan. Contact your dentist's office to see what they can offer you. If you don't currently have a dentist, you can find your own plan through a private insurance company or pay for dental services as you need them.

How to change plans during a Special Enrollment Period

If you need to change your dental insurance plan, you can do so during the yearly Open Enrollment Period, which runs from November 1 to January 15. Outside of this period, you can only change your plan if you qualify for a Special Enrollment Period. A Special Enrollment Period is triggered by certain life events, such as losing health coverage, moving, getting married, having a baby, or adopting a child. You usually have 60 days from the life event to enroll in a new plan, but it's recommended to report your change as soon as possible.

• Report the change: Update your application to reflect the life event that has triggered the Special Enrollment Period.
• Review your Eligibility Results: Check if you qualify for a Special Enrollment Period by reviewing your Eligibility Results.
• Shop for new plans: If you qualify, you can start shopping for new plans that meet your needs and budget.
• Enroll in a new plan: Select a new plan that suits your requirements and budget, and enroll before the deadline. Remember that you might have to submit documents to prove your life event.
• Cancel your old plan: Don't forget to cancel your previous plan to avoid paying for two plans simultaneously.
• Ensure continuous coverage: Make sure to pay any premiums due on your current plan to maintain coverage until the new plan takes effect.

Remember that the specific steps and requirements may vary depending on your location and the insurance provider. It's always a good idea to review the details of your plan and consult official government websites or your insurance provider for the most accurate and up-to-date information.

Frequently asked questions