Group Dental Plans

This benefit is an affordable way to pay for dental expenses through fully insured plans or self-funded insurance options. Most group dental plans operate on a 100/80/50 structure. This means that 100% of cleanings, exams, and x-rays are covered in an in-network facility. Additionally, 80% of basic services, which include simple extractions, cavities, and other minor procedures, are covered. Major services, such as root canals, crowns, bridges, and implants, have 50% coverage. Depending on the plan, services like periodontal and endodontic treatments may fall under either major or basic categories.

If someone utilizes an out-of-network provider, the carriers can process the claim in one of two ways. The first is as a MAC or Maximum Allowable Charge. For instance, if you go for a cleaning and your dentist is out of network, charging $200, but your carrier pays only $80, the dentist may balance bill you for the remaining $120. The second method involves a percentage of reasonable and customary (R&C) charges, typically between 80-90%. Using the same example, the carrier might pay $144 instead of $80 if the average cleaning cost in your area is $180, resulting in a balance bill of $56. Overall, the R&C percentage usually offers better value, albeit at a higher cost.

Orthodontia is also a covered expense, primarily for kids under 19, and is generally capped at a lifetime maximum of $1,000-$2,000. This means that if you switch from one carrier to another after utilizing your ortho benefit, it won't be covered by the new carrier. Furthermore, this benefit can add 15-20% to the premium for all employees under group health insurance.

Dental plans typically range in benefits from $1,000 to $5,000 per plan year. Higher benefits often come with higher premiums, so it's essential to explore various benefit levels to ensure you select the right one for your budget.

To illustrate how the benefit works, consider Kevin, who goes to the dentist for a root canal. The dentist charges $2,000 for the procedure. Kevin has a plan with a $2,000 benefit. Since a root canal is classified as a major service, the plan would cover $1,000 of the bill, leaving Kevin responsible for the remaining $1,000. While this amount is still significant, it is certainly better than paying the entire $2,000 out of pocket.