The Affordable Care Act (ACA) specifically stresses child dental care, but it makes dental care optional for adults. Some ACA plans include dental coverage, and ACA customers can also buy stand-alone dental plans. Adult dental benefits “are still optional,” according to a recent report by the American Dental Association (ADA), “with one implication being there are fewer regulations governing how dental benefits are offered to adults.”
Consumers are paying more than ever in premiums and co-payments for dental insurance, but according to the recent ADA report, many consumers are not getting any of what they’re paying for. The Association says that more than a third of the adults below the age of 65 who have private dental benefits did not submit one claim in 2013. “Clearly, many adult beneficiaries, or employers on their behalf, are paying for a dental plan they are not using,” the report concluded.
Just like basic medical care, we tend to spend more on dental care as we age. Those covered by dental insurance who are ages 19 to 34 pay an average of $492 per year for dental services; those between ages 35 and 49, $598 annually; and for those from ages 50 to 64, the average annual cost of dental care is $785.
WHAT ARE SOME OF THE ISSUES WITH DENTAL INSURANCE?
While it’s well-known that dental care is essential to good health – as any San Diego family dentist will confirm – the way dental insurance is handled has been subjected to plenty of criticism, and some of the criticism is justified. For example, medical insurance is typically structured so that patients have to pay more at the “front end,” but it generally covers everything beyond a specified dollar amount, while dental insurance often covers only half the cost of major procedures like root canals.
Some critics, in fact, suggest that most consumers should not even purchase dental insurance. They say that two annual preventive check-ups – the only care that most dental insurance pays for fully – cost roughly the same as the premiums a beneficiary pays in a year, so the insurance is simply unnecessary for many – patients could simply pay the same amount out-of-pocket directly to a dentist.
“Market rates” is the phrase for what dentists charge uninsured patients. The ADA’s researchers determined that the total premiums and copayments for private dental insurance actually exceed the market rate value of the dental care obtained by nearly 70 percent of adults with dental insurance coverage, and insurance company payments to dentists are significantly lower than market rates for the same services. The statistics show that 37 percent of adults with private dental insurance did not take advantage of any their benefits in 2013, including 44.5 percent of the adults between the ages of 19 and 34.
WHO WERE THE SUBJECTS OF THE STUDY?
The American Dental Association report explains who and what the researchers studied: “We examined 24,820,546 dental claims across 5,970,386 adults who were enrolled in a private dental benefits plan for 365 continuous days in our analysis…. Within each age group, we analyzed data across all adults with private dental benefits, regardless of whether they had any dental spending.”
Each adult will have to make the decision for himself or herself if purchasing dental insurance is worth the cost. If you are one of the millions of adults in the United States with no dental coverage, is an insurance policy really worth it? The answer probably hinges on whether or not you expect to need significant dental work and whether or not you expect to be paying big bills for healthy teeth.
Evelyn Ireland, who is the executive director of the National Association of Dental Plans, says that the largest number of dental insurance plans focus on diagnostics and prevention, covering two annual exams and cleanings, X-rays, and fluoride treatments. Carrie McLean, a consumer specialist with eHealthInsurance.com, tells us that the best reason to purchase dental insurance is to cover expensive procedures such as fillings, root canals, and crowns. McLean says, “It’s like health insurance – you’re really buying peace of mind.”
However, dental insurance plans do vary widely, so selecting the plan that’s right for you can be quite a challenge in a crowded, competitive, and frankly confusing market. The most commonly available coverage is called “100-80-50” coverage, which pays 50 percent for bridges, crowns, and major procedures, 80 percent for root canals, fillings, and other basic procedures, and 100 percent for routine diagnostic and preventive care like checkups and cleanings.
Overwhelmingly, most dental insurance coverage is provided to consumers through employee and group policies that charged a yearly premium between $234 and $432 per person in 2011, according to the National Association of Dental Plans. Carrie McLean tells us that the average annual cost of a dental insurance policy for an individual adult in the United States today is $360, while the American Dental Association says that paying out-of-pocket for two exams, two cleanings, and X-rays – in 2011 – would have cost $370. Most dental insurance caps the coverage at $1,500 a year, although you can pay a higher premium for a higher annual limit.
WHAT VARIETY OF COVERAGE IS BEST?
Dental insurance comes in three varieties: PPO, HMO, or indemnity plans. A health maintenance organization (HMO) limits consumers to the dentists and dental professionals in its own network. A preferred provider organization (PPO) lets consumers see the dentist they choose, but rates are usually lower for consumers who use an “in-network” dentist. An indemnity plan permits patients to see any dentist and generally pays some percentage of the cost. Dentists in a PPO network will usually provide services for less in out-of-pocket costs than the same services would cost under an indemnity plan.
It’s imperative for families to find the right dentist – someone you like and trust – and trying to find that right dentist while also looking for the right dental insurance can be exasperating. In southern California, one good idea is to speak directly with a San Diego family dentist about your dental needs, your family’s dental needs, and your dental insurance – or lack of it. Most dentists will find a way to help you, and if they can’t, they’ll refer you to someone who can. The most important thing is not to allow any confusion regarding dental insurance to keep you from getting the ongoing dental care that all of us need.