Dental Insurance Law and Legal Definition

Dental Insurance is an insurance coverage for individuals to protect them against dental costs. It insures against the expense of treatment and care of dental disease and accident to teeth. The most common types of dental insurance plans are Preferred provider organizations (PPO) or dental health maintenance organizations (DHMO). Both types are considered managed care.

Preferred Provider Organizations:

A preferred provider organizations ( PPO) falls somewhere between an indemnity plan and a dental HMO. 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. A group of dentists agrees to provide services at a deeply discounted rate, giving you substantial savings — as long as you stay in their network. Unlike the more restrictive DHMO, though, you can go out of network and still receive some benefits. Some typical features of these plans:

  • Monthly premiums
  • Annual dollar cap
  • You must stay within the approved network of dentists or pay higher deductibles and co-payments
  • Your average monthly cost: $20-25

Companies selling these plans are regulated by state insurance departments.

Indemnity Plans:

This type of dental plan pays the dental office (dentist) on a traditional fee-for-service basis. A monthly premium is paid by the client and/or the employer to an insurance company, which then reimburses the dental office (dentist) for the services rendered. An insurance company usually pays between 50% - 80% of the dental office (dentist) fees for a covered procedures; the remaining 20% - 50% is paid by the client. These plans often have a pre-determined or set deductible amount which varies from plan to plan. Indemnity plans also can limit the amount of services covered within a given year and pay the dentist based on a variety of fee schedules. Some typical features of these plans:

  • High deductibles before coverage begins (well-designed plans don't apply the deductible to preventive services)
  • Probationary periods on certain procedures that last up to a year
  • Annual dollar limit on benefits
  • Chose your own dentist
  • Your average monthly cost: $15 to $25
  • Companies selling these plans are regulated by state insurance epartments.

Direct Reimbursement Plans:

This is a self-funded benefit plan — not insurance — in which an employer pays for dental care with its own funds, rather than paying premiums to an insurance company or third-party administrator. You, the patient, pay the full amount directly to the dentist, then get a receipt detailing services rendered and the cost, which you show to your employer. The employer reimburses you for part or all of the dental costs, depending on your specific benefits.

Your company might reimburse 100 percent of your first $100 of dental expenses and then 80 percent of the next $500, and 50 percent of the next $2,000, with a total annual maximum benefit of $1,500. Or it might reimburse only 50 percent of your first $1,000, resulting in a $500 yearly cap. Some typical features of a direct reimbursement plan:

  • Neither you nor your employer pay monthly premiums
  • Freedom to choose any dentist
  • Typical employer cost: depends on the number of employees and
  • Benefits usually capped at $500 to $2,000 annually.

Dental HMOs:

These insurance plans, also known as "capitation plans," operate like their medical HMO cousins. This type of dental plan provides a comprehensive dental care to enrolled patients through designated provider office (dentist). A Dental Health Maintenance Organization (DHMO) is a common example of a capitation plan. The dentist is paid on a per capita (per person) basis rather than for actual treatment provided. Participating dentists receive a fixes monthly fee based on the number of patients assigned to the office. In addition to premiums, client co-payments may be required for each visit. Some typical features of these plans:

  • Monthly premiums (some require you to prepay a year's worth)
  • Co-payments for office visits
  • Free preventive or routine care
  • You must select from an approved network of dentists
  • May have an initial enrollment fee
  • Annual dollar cap
  • Your average monthly cost: $5 to $15
  • Companies selling these plans are regulated by state insurance departments.