Individual Dental Plans

This benefit is a affordable way to pay for dental expenses. Most plans fall under a 100/80/50 design. This means that 100% of cleanings, exam and x-rays are covered in an in-network facility. 80% of basic services are covered, which entail things like simple extractions, cavities and other minor services. 50% of major services are also covered. Major services are things like root canals, crowns, bridges and implants. Services like Periodontal and Endodontic treatments can fall under major or basic, depending on the plan. A big difference between group and individual dental plans is the waiting period many of the carriers place on the available benefit. For example, most carriers limit the percentage paid on major services to less than 20% the first year. It will increase the second year and may increase more the third year, depending on the carrier. Most plans do cover 100% of the preventative level of benefit from day one.

If someone utilizes an out of network provider, the carriers can treat the claim in one of

two ways. The first is as a MAC or Maximum Allowable Charge. This means that out of network providers will be paid on a scale established by the carrier. For example, if you go to have a cleaning done and your dentist is not in network, he charges $200 for the cleaning, but your carrier only pays him $80 for the service, the dentist will balance bill you for the $120. The second method is a percentage of reasonable and customary (R&C), with the percentage being between 80-90%. Same example as above, instead of paying $80, the carrier may pay $144 because the average charge for a cleaning in your area is $180. So you would be balance billed $56. Truly, the percentage of R&C is a better option, but it does cost more.

Orthodontia can also be a covered expense, but this is usually just for kids under 19, and is usually capped at a $1,000-$2,000 life time maximum. It is hard to find carriers that cover this benefit.

Dental plans will range in benefit from $1,000 to $5,000 per plan year. The higher the benefit, the higher the premium. It is important to look at a variety of benefit levels to ensure you are at the right level for the cost.

The way the benefit works is illustrated below:

Kevin goes to the dentist to have a root canal. The dentist charges $2,000 for the root canal. Kevin has a plan with a $2,000 benefit and is in the 4th year of his coverage and has maximized his major level of benefit at 50%. Since a root canal falls under major service, the plan would pay $1,000 of the bill and Kevin would be responsible for the other $1,000. While this is still a lot of money, it is better than paying the full $2,000.