This article will help you understand four key issues:
- The difference between a full coverage dental plan and a basic plan
- Why better dental care helps your overall health
- Why it’s worth it for individuals to buy – and for employers to offer – full coverage
- What really matters in a dental plan
While the terms “full coverage” and “basic coverage” are frequently used in describing different kinds of dental insurance, there’s no strict industry definition as to what needs to be in either type of plan. So what’s the difference between full and basic?
A basic dental plan covers preventive care such as checkups, cleanings, x-rays, and a few basic procedures, like cavity fillings. Full coverage plans cover much more – and often at a lower out-of-pocket cost to you. For example, they may cover a wider range of preventive procedures such as fluoride treatments and sealants in full or with just a small copay.
A good full coverage plan may cover other types of procedures, including:
- Basic restorative care: This includes fillings, extractions, and non-routine X-rays
- Major restorative care: Bridges, crowns, dentures, and the like
- Orthodontic treatment: Braces and other types of teeth aligners
Basic and full coverage plans may require you to see an in-network dentist
You may have heard about Dental Health Maintenance Organizations (DHMOs), also known as Managed Dental Care plans,and Dental Preferred Provider Organizations (DPPOs). In a DHMO, you have to see an in-network dentist, even if you have a full-service plan. Their networks are more limited than a PPO plan, but the trade-off is generally lower costs and a simpler fee structure. A DPPO also has a network of dentists, but typically lets you go out of network to see another dentist. But if you go with a large insurer with a broad provider network, your current dentist may well be “in-network.”
It’s almost always worth your while to see an in-network dentist in a DPPO because the insurance company negotiates discounted fees on your behalf. For example, if your dentist typically charges $100 for a filling, when they’re in-network you may only be charged $60-$70 – even you haven’t met your deductible yet.
Full coverage doesn’t mean all costs are covered
Even if you go to an in-network dentist, the cost you pay for a given dental treatment may vary widely depending on the provider and specific plan you choose. When you’re looking at a plan's details, the following items should be clearly spelled out:
- Deductible: The amount you have to pay before the plan starts to pay for treatments. DPPO plans tend to have deductibles, but many DHMO plans do not.
- Coinsurance: The percentage of costs you have to pay for a visit or treatment once you’ve met your deductible. With a DHMO, there isn’t a deductible, and you’ll typically pay a flat fee depending on the services received.
- Annual Maximum: The total amount your plan will pay you in a given year. You have to pay for any treatments over that amount – but remember: if you go in-network you’ll still be able to take advantage the plan’s discounted fees.
In addition to those costs, you have to pay your monthly premiums. DPPOs tend to have higher premiums than DHMOs, largely because DPPOs have fewer restrictions. However, if you get your dental plan through work, your premiums will tend to be lower for either type of plan because you’re paying group rates – it’s like buying in bulk.
Dental care and oral health shouldn’t be considered optional or secondary. Guardian studies – and a growing body of third-party research – show that maintaining good oral health can help adults avoid or better manage serious health-related issues:1
- Diabetes: Periodontal infections contribute to problems with glycemic control, which compromises the health of diabetic patients.
- Heart disease: The inflammation associated with periodontal disease has a high potential to contribute to coronary artery disease. Good oral health can lower that risk.
- Pregnancy: Studies have indicated that mothers with high levels of certain oral bacteria were found to have children with similarly high levels of bacteria, along with a higher risk of tooth decay.
- Self-esteem: Research shows that healthy teeth and gums are important to a person’s self-esteem and how they feel about themselves.2
All this should come as no surprise. It’s hard to be a happy, productive person when your mouth hurts and you’re worried about what’s happening with your teeth.
First of all, try to think about your dental care needs. If you’re young, single, and have never had oral health problems, a basic plan may be a good choice. But if you’re not so young, or you or your spouse have had issues – or you have kids – then you should look into getting a full coverage plan.
Next, think about which dentist you want to see. When people find a dentist they like, they tend to stay loyal to them: Over 60% of working Americans have been going to the same dentist for at least three years, and 32% have been with the same dentist for 10 years.3
If you have a dentist you want to stay with, look for a DPPO (or a similar type of plan called a DEPO); then check with your dentist to see if they’re part of the plan’s provider network. Plans with a large provider network will increase the odds of your dentist being in-network.
But what if cost matters more to you than loyalty to a specific dentist? A DHMO might be a better value for you. However, as their networks tend to be limited, you might have to go a little farther out of your way to get the care you need.
Look at the features and design of the plan you’re considering. Some of the terms may seem confusing at first, but the concepts are actually pretty straightforward. As we noted before, you should look at the premiums, deductible, coinsurance, and annual maximum to understand all the costs of the plan. In addition, you should pay attention to such things as:
- Types of services and treatments covered: You may not recognize the names of all the procedures covered—but the longer the list, the better.
- Waiting periods: Major procedures, such as root canals, usually have a waiting period (for example, 6 months) before they are covered. So don’t wait until your teeth hurt to get a plan!
- Primary dentist requirement: This is typical of DHMOs but some DPPOs also have this requirement. It means that you have to go through your regular dentist to get a referral to see a specialist.
How much does a full coverage dental plan cost?
Prices vary by carrier based on the age of each person in your family being insured, and where you live. Your employer may offer different levels of coverage and pricing based on tiers (e.g., platinum, gold, silver). Talk to your HR department to learn what they offer.
Everybody wants to be healthier, so the benefits of choosing a full coverage dental plan should be clear. And if you work for a company that offers a full-coverage plan, you may get an even better value.
A growing number of companies are realizing that better preventive care can help improve employee wellness and productivity, while actually reducing their overall claims costs. Working Americans who get regular preventive care are more likely to report better oral health, and they’re less likely to need expensive major treatment over time.
In fact, a recent Guardian study found that employer groups that spend more on preventive care have 16% lower combined dental claims costs. Companies have an incentive to offer plans that make preventive care more accessible to employees. After all, the perceived cost of dental services is the main reason why 4 out of 10 adults choose to forgo dentist visits.4
How can an employer’s plan increase the use of preventive services? By encouraging employees and their families to go for regular cleanings and exams. Ways to do that include:
- Covering preventive services at 100% (not 80% or 90%)
- Including a minimum of two cleanings per year
- Adding a third cleaning, especially for those with other medical risks
- Expanding their plan’s list of preventive services
Can you get full coverage dental insurance without a maximum?
Yes. DHMOs typically don’t have an annual maximum, but your provider choices are limited. DPPOs, which have larger networks, typically have an annual maximum that varies by provider and plan. If you want the larger network of a DPPO but expect to have significant dental expenses, then look for a plan with a higher annual maximum.
Is it worth having full coverage dental insurance?
Guardian claims data shows that dental plan members who received regular preventive care (i.e., received an oral exam and cleaning at least once a year), required less major dental services and, consequently, experienced lower out-of-pocket costs over a three-year period.5
Does dental insurance cover teeth aligners?
Depending on your plan, you may be able to use your insurance, or pay with tax-free dollars from your HSA or FSA plan.
How to get a full coverage dental plan
If you or your spouse have dental benefits through work, that’s almost always the way to go. Companies get lower group rates than individuals typically can, and they can tailor their employee dental plans to provide a fuller set benefits, including comprehensive preventive care.
If that’s not an option, consider buying directly from a dental plan provider. Since all major providers will offer a few options, take the time to compare the plans offered – and remember that the plan with the lowest premium may not provide the best value for your family’s needs.
Finally, if you’re an employer or broker looking for cost-effective dental strategies that can help keep your employees healthier and more productive, consider talking with a Guardian Representative to find out about the options available for your company.