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Dental Benefits Basics

Who has dental benefits today?

Who has dental benefits today?

At year-end 2016, there were approximately 249.1 million Americans or 77 percent of the population with dental benefits[1]. The large increase in publicly funded benefits is primarily the result of improved CMS data on adults with access to Medicaid dental benefits.[2]

Two-thirds or 164.2 million Americans have private dental coverage. About 90% of Americans with private coverage get their benefits through an employer or other group program like AARP. Another 7.1% buy individual coverage[3] while just less than 3% obtaining dental benefits as part of a medical plan. Another 83.9 million Americans receive dental benefits through public programs like Medicaid, the federal Children’s Health Insurance Program, Medicare Advantage, and Indian Health Services. 
Who has dental benefits today

Americans with dental benefits are more likely to go to the dentist, take their children to the dentist, receive restorative care and experience greater overall health, according to the National Association of Dental Plans (NADP) report, The Haves and the Have-Nots: Consumers with and without Dental Benefits.

This report clearly shows that access to dental care is improved with dental benefits and that dental care improves oral health. Given increasing connections between oral and overall health, dental coverage is critical for all Americans. The choice for us as individuals and for our health care system is to pay for dental care now or pay more for medical treatment of dental complications later. (A “Consumer White Paper” based on data from this report can is available from NADP.)

Some 74 million Americans had no dental coverage in 2016. With the overall medically uninsured rate dropping to about 8.6% in the first quarter of 2016 as the result of the ACA; the dentally uninsured rate has increased to about 4 times the medically uninsured rate—even with dental coverage expansions. In part, this is due to the lack of dental coverage in traditional Medicare. Those over 65 may still have coverage through an employer, be able to purchase individual dental coverage or obtain dental coverage as a supplemental benefit through a Medicare Advantage plan. However only 52.9% reported having dental coverage on the 2016 NADP consumer survey while virtually 100% of seniors have medical coverage under Medicare.

Individuals without dental benefits are more likely to have extractions and dentures and less likely to have restorative care or receive treatment for gum disease. Furthermore, those without dental benefits report higher incidences of other illness; they are

  • 67 percent more likely to have heart disease;
  • 50 percent more likely to have osteoporosis; and
  • 29 percent more likely to have diabetes.

They also visit the dentist less frequently—missing the opportunity for prevention and early treatment. Many of them account for over 2 million visits to emergency rooms for dental treatment annually[4].


[1] 2017 NADP Dental Benefits Report: Enrollment

[2] NADP used data from 25 states that provide treatment for at least preventive services; states (13) with emergency only dental benefits were not included.

[3] While individual dental coverage is only 7% of total coverage in 2016, just 5 years ago in 2011 it was only 2% of coverage.

[4] The Healthcare Cost and Utilization Project (HCUP) National Emergency Data Sample

 
What are the different types of dental benefits products?

What are the different types of dental benefits products?

There are four key types of dental benefit products with significant market shares today, i.e. dental HMOs, dental PPOs, dental Indemnity plans, and discount dental plans. Today 82% of all dental policies are DPPOs.

A common set of definitions is helpful in seeking dental benefits coverage. The terms we use are defined below:

Dental HMOs --refers to dental benefit plans that provide comprehensive dental benefits to a defined population of enrollees in exchange for a fixed monthly premium and pays for general dentistry services primarily under capitation arrangements with a contracted network of dentists. Enrollees must use network dentists to obtain coverage except where a point of service provision allows them to opt out of the network but at reduced coverage.

Dental PPOs --refers to dental benefit plans that have contracts with providers for the express purpose of obtaining a discount from overall fees. Enrollees receive value from these discounts when using contracted providers but may go outside the network of discounted providers but with a reduction in coverage. Providers are reimbursed on a fee-for-service basis after care is provided at either the discounted rate or the “UCR” (usual, customary, reasonable) rate recognized by the plan. Individuals are not balance billed for the difference between the negotiated fee and the actual fee that the dentist charges.

Dental Indemnity Plans--refers to benefit plans where the risk for claims incurred is transferred from employer to a third-party insurer for a specified premium and providers are reimbursed on a fee-for-service basis and there are no discounted provider contract arrangements whereby the provider agrees to accept a fee below their customary fee.

Discount Dental or Dental Savings Plans –refers to non-insured programs in which a panel of dentists agrees to perform services for enrollees at a specified discounted price, or discount off their usual charge. No payment is made by the referral plan to the dentists; dentists are paid the negotiated fee directly by the enrollee. These plans are sometimes referred to as “access plans,” “savings plans” or “discount plans.” 

What do dental plans normally cover?

What do dental plans normally cover?

There are seven basic areas of dental care that policies cover. With individual policies, often only the first four will be covered in the initial year of a policy with the last two available in later years. Orthodontics is usually a rider for both individual and group policies that can be selected when relevant.

  1. preventive care, i.e. cleaning, routine office visits;
  2. restorative care, i.e. fillings and crowns;
  3. endodontics, i.e. root canals;
  4. oral surgery - tooth removal and minor surgical procedures such as tissue biopsy and drainage of minor oral infections;
  5. orthodontics--retainers, braces, etc.
  6. periodontics - scaling, root planning and management of acute infections or lesions; and
  7. prosthodontics--dentures and bridges.

Dental benefits overcome consumers’ top concern about getting the care they need—cost. The seven types of procedures are broken into three areas of coverage for payment purposes, i.e. preventive, basic and major.

Most plans cover 100% of preventive care and apply co-payments, either as a dollar amount (DHMOs) or as a percentage (DPPOs and Dental Indemnity/ or Traditional Insurance) to other levels of care. Preventative care usually includes periodic oral evaluations, x-rays and sealants. (NOTE:  Sealants may be limited to certain age groups.)

Basic procedures, i.e. office visits, extractions, fillings, root canals, and periodontal treatment for gum disease, are typically covered at a lower percentage amount, for instance 80% (sometimes 60%), or with lower dollar co-payments in the case of a DHMO.

Major procedures, i.e. crowns, bridges, inlays, and dentures are usually covered at the lowest percentage, such as 50% or a higher dollar co-payment in the case of a DHMO. Root canals are also sometimes covered in this category rather than as a Basic procedure, so check your coverage. Some carriers now offer coverage for implants under this category of coverage.

Just under half of dental PPOs, the predominant dental product in the market, have a maximum annual benefit above $1500—half are less than $1500. Deductibles for these products are usually between $50 and $100. Some carriers now offer policies that roll some portion of an unused annual maximum over until the next year.  Whatever the annual maximum, only 2-6% of Americans with dental benefits hit their annual maximums.
What do dental plans normally cover

In 2015, the portion of Americans hitting their annual maximum jumped to about 9%. If this change becomes a trend, it could be a key factor in employers increasing annual maximums. In most years, employers resist changing annual maximums because of higher premium costs for higher annual limits.  NOTE:  DHMOs rarely have an annual maximum while most dental indemnity product annual limits parallel DPPO limits.

What are typical dental procedures and what do they cost?

What are typical dental procedures and what do they cost?

Dental procedures are billed under procedure codes established by the American Dental Association. The 50 most commonly used codes encompass 95% of all procedures submitted to insurance carriers each year. These 50 codes can be grouped into the following types of procedures:

  1. Oral Examinations (4)
  2. X-rays (6)
  3. Tooth cleanings (2)
  4. Application of Fluoride (3)
  5. Sealants (usually limited to children) (1)
  6. Fillings either Amalgam /silver (3) or Composite/white (8)
  7. Crowns (7)
  8. Root Canals (3)
  9. Treatments for gum disease (5)
  10. Extractions (4)
  11. Emergency relief of pain (1)
  12. Anesthesia (2) and
  13. Consultations

NADP does not collect information on dental fees. The ADA publishes a survey of dentist fees which is available from their website:  Survey of Dental Fees 2016. The data in this survey is in broad geographic areas. More specific, up-to-date information is available to consumers for particular procedures by zip code area from FAIR Health’s Dental Cost Lookup.

Is there any new dental coverage under the Affordable Care Act?

Is there any new dental coverage under the Affordable Care Act? 

Since the implementation of the Affordable Care Act in 2014, there is a new structure for children’s dental benefits. On the public “marketplaces” and for policies sold to small employers of 50 or fewer employees and to individuals, pediatric oral health services are defined as part of Essential Health Benefits (EHB). The pediatric services that meet EHB requirements through a standalone dental plan must meet new AV requirements, cannot have annual maximum limits and must limit consumer out of pocket expenses to $350 a year for one child or $700 a year for a family when the coverage.

While pediatric oral health services in a medical plan also cannot have annual limits, the pediatric oral services that are covered can be subject to the full medical deductible which averaged $2900 in 2015. And the limits on consumer out-of-pocket expenses are much higher under medical plans. In 2017, limits on consumer out-of-pocket spending is $7,150 for an individual medical plan and $14,300 for a family medical plan. Pediatric oral services are included in these limits.

Adult coverage and children’s coverage through large employers (51 and more employees) remains under the structure described under the question, “What do dental plans normally cover?”

Do public programs like Medicaid and Medicare cover dental care?

Do public programs like Medicaid and Medicare cover dental care? 

Medicaid covers comprehensive dental care for children through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which federal law requires all states to provide to children.

In 2009 a new requirement to provide dental coverage was also added to the Children’s Health Insurance Program that also allows a family to buy just dental coverage for their children if the family has medical coverage but no dental coverage.

Medicaid Adult Dental Coverage expansion map

While states are not required to provide adult dental services under Medicaid, most provide some level of dental services for adults. Only 3 have no coverage at all. (See attached chart from a webinar presentation by DentaQuest, an NADP member plan, in 2016.) There is a strong state-by-state effort to assure Medicaid dental treatment for adults at some level. The two million visits to emergency rooms annually for dental services costs over $1.6 billion; Medicaid pays for about 1/3 of these charges, i.e. $520 million[1].

Traditional Medicare does not cover dental procedures. However, about one-third of seniors buy Medicare Advantage plans rather than enroll in traditional Medicare. According to an analysis by Avalere[2], in 2017 about 63% of Medicare Advantage plans include some level of dental benefit, i.e. about 12 million seniors in MA plans. This is projected to grow to 14 million by 2019. There are also group benefits available to seniors such as AARP’s endorsed group dental program for their members.



[1] Cassandra Yarbrough, M.P.P.; Marko Vujicic, Ph.D.; Kamyar Nasseh, Ph.D.; Estimating the Cost of Introducing a Medicaid Adults Dental Benefit in 22 States, ADA Health Policy Institute, March 2016 Available at http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0316_1.pdf?la=en.

[2] Analysis of CMS data by Avalere was funded by NADP for a webinar broadcast in June 2017.

What should I think about before I shop for coverage?

What should I think about before I shop for coverage? 

Before you shop, think about what is most important to you or your employees:

Is it most critical for out-of-pocket expenses to be predictable and low If so, a dental HMO might be best suited to your needs or those of your employees. Dental HMO co-payments are published and offer more predictability as they are usually stated as specific dollar amounts. As well premiums are also lowest among insured dental benefit products and there is rarely an annual maximum on care. As well they typically have the lowest deductibles. In 2015 NADP found 93% of DHMO deductibles under $25 while only 15% of DPPO or dental indemnity deductibles are at this level. The trade-off for this predictability and lower cost is a requirement that the consumer go to a dentist in the network for care. Only when a dental emergency occurs outside of the consumer’s home area is a dentist that is not in the network paid for dental care.

Do you or your workforce have a greater tolerance for cost-sharing and an interest in a broader network of dentists?  If so a dental PPO or a Discount plan may suit you. Co-payments in dental PPOs are usually stated on a percentage basis and some coverage is still provided if you or your employee goes outside the network for care. DPPOs have an annual maximum on the amount the carrier will pay for services and about 72% of deductibles are between $50 and $100. Discount plans do not pay anything toward the cost of care; they simply make a network of providers available to the consumer that offer services at a discount. So, while Discount plan monthly fees are lower than dental PPO premiums, the full cost of care must be paid out-of-pocket at the discounted rate.

If freedom to choose a dentist is paramount a dental Indemnity plan may be your best match. Annual maximums and copayments are similar to those of DPPOs. Premiums are often slightly lower than DPPOs as there is no network organization cost to the plan. While there is no restriction on the choice of dentist, there is no discount on fees, so fewer services may be paid for by the indemnity plan which means more potential consumer out-of-pocket cost.

How can I find a dental benefit plan?

How can I find a dental benefit plan?

The NADP site has a link to the NADP Directory; use the button on the home page marked “Find a Dental Plan.”  This Directory provides a way to search by state and “individual” or “group” coverage for the carriers that offer dental benefits in your state. Since NADP members write more than 93% of all the dental benefits in the United States, this search will usually provide a list of 6 to12 companies that write coverage for individuals and many more for groups. Some of the companies offer only discount products or DHMO while others will offer DPPO or dental indemnity, so know the type of coverage you are looking for before you do your search.

Other web sites connect employers looking for group coverage to carriers:

Websites that focus on individual purchases include the following: 

You can also look up the Delta plan that offers individual coverage in your state on the Delta Dental Plans Association site, DeltaDental.com.

NOTE:  Listing contact sites for coverage is not an endorsement of that site or their products.


[1] Healthcare.gov is the federal website offering medical and dental coverage with subsidies for families with incomes up to 400% of poverty. The website is open to individuals that do not have an offer of adequate coverage through an employer.

What do dental benefits cost on a group basis or if I buy them directly as an individual?

What do dental benefits cost on a group basis or if I buy them directly as an individual?

For most the cost of dental benefits is less than your daily cup of coffee. Depending on what you buy that might be regular coffee or it might be Starbucks. (NOTE:  Costs will vary by area of the country and coverage.)

Individual policies are generally more expensive than a group policy and the coverage may also be somewhat limited. Individual policies generally do not cover orthodontia. There may also be other coverage limitations and/or waiting periods particularly for major procedures. The estimated national average monthly and annual dental premiums for individual products have not been collected since 2009. At that time they ranged from $4 to $15 more than similar group products for individuals and $20 to $35 more for family coverage.  

Depending on the type of dental benefit—DHMO, DPPO or Dental Indemnity, the employee’s premium is about the cost of having dinner out once a month—ranging from about $14 to $30.50 monthly or $168 to $366 on an annual basis in 2016[1]. Even at the high end of that range—dental benefits cost annually what medical premiums cost an individual on a monthly basis. Dental premiums for 2016 for employer groups with coverage are outlined below as national averages for typical group coverage for all size groups[2]:

Employee only:

  • DHMO -  $14.06 a month--$168.72 annually
  • DPPO - $24.49 a month--$293.88 annually
  • Indemnity - $30.57 a month--$366.84 annually

Employee & Family[3]:

  • DHMO -  $27.08 a month--$324.96 annually
  • DPPO - $48.36 a month--$580.32 annually
  • Indemnity -  $56.73 a month--$680.76 annually

Discount Dental Plan fees can range from a few dollars a month to $10 or $12 dollars a month for an individual or $20 to $30 a month for a family.  


[1] NADP 2016 Dental Benefits Report: Premium and Benefit Utilization Trends, February 2017

[2] NADP 2016 Dental Benefits Report: Premium and Benefit Utilization Trends, February 2017. Average of all groups is displayed; premiums for small groups (under 50) will usually be higher than the average shown here while the largest groups (500 or more) will be lower.

[3] Family coverage extends to the insured, spouse and dependents—no matter the number. There are usually separate, lower rates for an insured with a single dependent. So a family policy covers 3 or more individuals.

Are dental plans accredited? Is there any method of licensing or registration?

Are dental plans accredited? Is there any method of licensing or registration?

NADP member companies are licensed where appropriate in their states of operation and do support a consumer access and rights policy. There is no type of accreditation service or seal of approval for all functions of companies that offer dental benefits. Some dental plans have received separate certifications of their dental clinics, provider credentialing, claims processing or utilization review process.  

Separate from NADP, there is also an affiliation of Delta Dental Plans, i.e. DDPA—their website and that of NADP provide the names of companies that are most active in the dental benefits arena. NADP members write over 90% of the market; DDPA’s members write about 26% of the market—together our associations represent virtually all of the market.

Also check with state insurance or health regulatory authorities to make certain that the dental company you are considering is licensed if the company provides a dental HMO, dental PPO or dental Indemnity plan. Discount dental plans are not licensed in most states as they are not insurance products although an increasing number of states are requiring licensure or regulation. Regulatory authorities also track complaints and most of their published summaries show dental products in the lowest ranges of consumer complaints.

IMPACT of PPACA on Dental Benefits

IMPACT of PPACA on Dental Benefits

With the passage of PPACA in 2010, a new requirement for coverage of oral health services for children under age 19 will became part of required coverage in the individual and small group market beginning in 2014. There is significant confusion about how the children’s oral services provision is being included in policies. The coverage of 22.9 million children that were covered in the small group market prior to 2014 under separate dental plans could be duplicated in some part by a medical plan that makes pediatric dental benefits subject to the medical deductible or waives that deductible for prevention thereby creating a “prevention only” benefit. For more details on the coverage options under the Affordable Care Act (ACA) use these links to information on NADP’s website: 

  • NADP Infographic: Dental Benefits Choices for Children
  • NADP Issue Brief: Dental in the Marketplaces: Consumer Tips on Shopping for Dental
  • NADP Issue Brief: The Basics of Dental Coverage and the ACA

The Pew Center for the States estimated that 5.3 million children would be added to coverage when the ACA went into effect primarily through public programs like Medicaid and CHIP.

In 2014, only about a half-million children applied for commercial health coverage in state or federal exchanges. It is not known whether these children obtained dental coverage through the health plan that was selected. Only 26,600 selected stand-alone dental plans (SADP) in the federal exchange as seen in the percentages included chart below. As well, while an additional 8 million were enrolled in public programs including Medicaid and CHIP which cover pediatric dental; the percentage of those in the 0-18 age bracket that are new enrollees is not known.

In 2015, the number of commercial applications for medical coverage in the 0-17 age group through state and federal Exchanges increased to 890,017 with about 100,000 of these applying for standalone dental coverage. Again, it is not known whether the other 790,000 obtained dental benefits as part of their medical plan. So clearly any increase in the total number of children with dental insurance would have to be primarily through state Medicaid and CHIP programs.

Trends in Exchange Selections of Coverage 2014-2017

In 2015 about 1/3 of the medical policies offered on marketplaces included a pediatric dental benefit. Of those 90% made that benefit subject to the medical deductible that averaged just under $3000. Of the 90% two thirds waived the deductible for diagnostic and preventive care making the pediatric benefit a “prevention only” benefit.

In 2016 the number of children applying for commercial coverage again increased; it was 1,068,631. Of these 115,304 applied for separate dental coverage. Again, no information was made available as to whether the other applicants obtained medical policies with pediatric dental coverage. About 1.4 million individuals overall applied for separate dental coverage, i.e. primarily adults.

In 2017, the number of children applying for commercial coverage through all public exchanges was approximately level to the prior year, i.e. 1,068,082 vs.1,068,631 the prior year. The number of overall applications in all public exchanges was down slightly as well, 12,200,000 vs. 12,600,000 the prior year. Overall there were about 1.9 million public exchange applications for SADPs with approximately 134,000 of these applications for children in the 0-17 age group.

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