Stacey N. Block, D.D.S.

About dental insurance


Dental “insurance” is in quotation marks because, in reality, it is not insurance at all. It is a benefit that one’s employer provides to offset the cost of regular and routine dental care. Insurance is a way to protect one from an unexpected financial loss due to illness or accident such as slipping and breaking a leg or being diagnosed with a disease, or theft, fire or flood. These examples can often result in great expense to the victim, sometimes causing catastrophic financial problems, and insurance acts as a safety net. Most dental “emergencies” are not unforeseeable results of accident, but rather of neglect, and even in the case of a true dental emergency, the cost is rarely even close to that of its medical counterpart.

Dental benefits policies provide a set dollar amount per year that is available to the covered individual for a variety of dental services. The levels and percentages of coverage are determined by your employer and are based on the amount they wish to pay in premiums. Preventive care (exams, cavity detecting x-rays and dental cleaning) is most often covered at or near 100% while the individual is required to participate financially in a portion of the cost of other dental services, such as fillings, crowns, extractions, etc.

For this reason, Dr. Block stresses that the BEST DENTAL INSURANCE IS REGULAR PREVENTIVE DENTAL CARE! The smartest way to avoid extensive and/or expensive restorative dental treatment is to get regular dental check-ups and take care of problems when they are small.

These days conversations about benefits can sound like alphabet soup! Here is a short description of each type of plan:

HMO: Health Maintenance Organization

Sometimes, in dentistry, you will hear it called a DMO or a DHMO. This type of plan only pays benefits if you receive services from a doctor who is contracted to provide care with this company. If you choose to see a doctor who is not a contracted “provider”, your insurance company will not pay any part of the cost (with a couple of exceptions for emergencies.) The doctors who participate in HMOs have agreed to accept the fees that the HMO has negotiated with them in exchange for the referral of a population of patients. 

Patients often find that their scope of covered benefits is limited to the least expensive alternatives such as silver amalgam fillings instead of tooth-colored composite fillings, or a base metal crown instead of a tooth colored porcelain crown. 

Most often, the premiums for a dental HMO will be lower and, thus more attractive to dental "insurance" consumers.  But, buyer beware.  Be sure to read all the limitations with an HMO plan before committing.  Remember the saying, "You get what you pay for."

PPO: Preferred Provider Organization

A PPO gives the patient a choice between seeing an in-network, contracted doctor or any out-of-network doctor he or she chooses. Reimbursement levels to contracted doctors are often higher than those of HMOs, but it is still the insurance company who sets the fee regardless of what it costs the doctor to provide the care. The PPO will pay benefits for services provided by an out-of-network doctor, usually in the same amount they would pay an in-network doctor. The patient is then responsible for paying the difference between the insurance benefit and the doctor’s fee. Since the out-of-network doctor has not contracted with the insurance company, his or her fees will generally be higher than the in-network doctor’s fees. How much of a difference depends on the policy itself and the particular procedure being performed. This by no means indicates that the out-of-network doctor is overcharging.  Fees will vary from office to office and are based on the level of personal service, the quality of the materials and dental laboratories being used, the level of technology the office is equipped with and the level of expertise of the doctor in a particular procedure. 

Indemnity “insurance”

This type of plan pays a percentage of the doctor’s fee. Most plans pay 100% of preventive services, 80% of basic services (fillings, gum therapy, extractions, root canals, etc), and 50% of major services (crowns, bridges and dentures).
There is an upper limit on the amount at which they will reimburse, and this is called "UCR" (usual, customary and reasonable).

To see a detailed description of "UCR", scroll down to the section below.

UCR: Usual, customary and reasonable

You will find that the dentistry is quite sensitive about this term. This is because it leads the patient to believe that the insurance companies know what is “reasonable” or “usual” in our profession. Most people are led to believe that this UCR is an average of the fees charged by dentists in certain zip codes. This is not accurate and, in fact, if you ask five different employees of the same insurance company how they arrived at their UCR fees you will likely get five different answers. The truth is that UCR fees are determined in many different ways by many different insurance companies. Ultimately, the UCR fees are the maximum fee that the insurance company will consider when determining the amount of reimbursement under your indemnity plan.

Example: You have 100% coverage for preventive care. If Dr. A charges $60 for a dental cleaning, Dr. B charges $75, Dr. C’s fee is $85 and Dr. D’s is $90 and your plan has a UCR of $83 for a cleaning, then your reimbursement from the insurance company will be $60 for Dr. A’s services, $75 for Dr. B’s and $83 for Dr. C and D’s since both of their fees are above the insurance company’s URC. Therefore, in reality you had 100% coverage for Dr.s A and B, 97% coverage for Dr. C and 92% for Dr. D.

This is not to say that Dr.s C and D overcharged you. It is possible that your insurance company has not increased their UCR limits for several years, or taken into account that these two doctors practice in a neighborhood where the office rents are higher causing them to have to charge a bit more to cover expenses. In fact, it is very possible that Dr. A has not increased his fees in several years and is not keeping up with the cost of providing care.

The frugal consumer might think, based on this description of UCR, that it is wise to “shop” for the lowest fees in the area for each procedure to lower his out of pocket expense for dental care. However, it is most likely that from office to office the fees for each procedure will vary. A cleaning might cost $3 more in office #1 than office #2, but their cavity detecting x-rays might be $5 less. In the end, it all "evens out".

More important than shopping for the “cheapest” fee for each procedure is finding a dental home where you feel welcome and comfortable. Forming a trusting and longstanding relationship with your doctor and having someone who truly knows you and your teeth is invaluable.


Please feel free to contact our office if you have any questions about your dental benefits. We'll be happy to help.