With terms like PPO, HMO, in-network, and out-of-network to describe dental benefits, it’s no surprise that many don’t understand how to make the most of their plan. This means you may be overlooking benefits that are critical to maintaining your oral health.
Don’t settle for just what you understand as part of your coverage. Read on for 5 simple tips to take advantage of everything your plan has to offer.
Tip #1: Take Time to Understand Your Plan
The best way to take advantage of your plan is to ensure you know the type of plan it is and its deductibles, copayments, and annual maximums.
There are two main types of dental plans:
- HMO Plans – With an HMO, you’ll be required to choose a dentist in your primary network to handle most of your needs. You are charged a relatively low co-payment for office visits, procedures, etc. There is no coverage if you visit an out-of-network provider. HMOs typically have no deductible or maximum.
- PPO Plans – With a PPO, you have the option to see both in-network and out-of-network providers, but coverage is better if you stay in network. Once you hit your deductible, you are reimbursed for a percentage of office visits, procedures, etc. The percentage may vary depending on the treatment and is much higher if you see an in-network dentist.
Key things to understand about your plan are its:
- Deductible – The dollar amount you must pay for covered services prior to claiming benefits under your plan.
- Copayment – A fixed dollar amount you must pay when you visit your dentist. Some plans with copayments don’t have a deductible whereas others may have both.
- Annual Maximum – The maximum amount a plan will pay for dental care for an individual or family during a specific benefit period (often, benefit periods last for 12 months).
Tip #2: Take Advantage of All Benefits Covered Under Your Plan
In addition to understanding the basics of your plan, it is important to explore all of the associated benefits.
Most individuals are aware of and will use diagnostic and preventative services for professional cleanings every 6 months. These services are often covered in full by HMO plans and between 80% and 100% by PPO plans.
However, there are other benefits that should be included both in your plan booklet and online. These benefits may cover restorative care (like fillings), major restorative care (like crowns and bridges), as well as orthodontic care. By doing your research, you can determine what procedures are covered, what limitations each procedure has, and if there are any exclusions.
Tip #3: Use a Dentist in Your Network
One of the most significant challenges for many individuals is determining whether or not a dentist is in their network. This can be particularly difficult for plans that have multiple networks because dentists may participate in all or some of them.
If you choose a dentist that is out of your network, the amount of insurance coverage you receive for your treatments will vary. As such, seeing an in-network dentist allows you to maximize your benefits.
Coverage will differ if you go out of network on either type of dental plan:
- HMO Plans – If you visit a dentist other than your primary or a referred specialist, your services won’t be covered (even if that dentist is also in your network).
- PPO Plans – PPO plans allow you to visit any licensed dentist and you will still be covered. However, choosing a dentist in your network offers top savings (allowing you to maximize your benefits and coverage).
Tip #4: Control Expenses with Treatment Plans
To maximize your benefits, it is best to schedule treatments in advance to align with your annual maximum. In many cases, you can strategically plan multi-stage treatments with your dental professional to minimize your costs as much as possible. Of course, it is also important to be prepared for unforeseen dental emergencies.
Tip #5: Track Claims and Remaining Benefits
Track claims as you receive treatment so you are aware of when you are approaching your annual maximum. After each appointment, review your treatment summary to see what your carrier covered. Then, subtract this amount from your annual maximum to calculate your remaining coverage for the given benefit period.
Get What You Pay for by Maximizing Your Benefits
You sign up for dental insurance for the benefits and you should receive what you paid for. By utilizing each of the tips above, you can make the most of all your benefits and keep your smile looking great.
If you would like to discuss how to best maximize your child’s dental benefits, please contact us:
Dr. Geri-Lynn Waldman DDS,
75 Crystal Run Road, Middletown, NY 10940