There are many reasons why you’d want to get a private dental insurance plan. You might be tired of not getting the coverage you want, either through your employer or Medicaid. Or maybe you want to have more control over your benefits and out-of-pocket expenses.
You’re ready to buy your own dental insurance plan, but where do you start? Here are the first four steps you can take to get the private dental insurance plan that will keep you and your family healthy.
1. Who will need coverage?
You need to determine exactly who in your family will need coverage. Is it just yourself, or do your spouse and dependent child (26 years old or under) need coverage too?
If you already have a medical insurance plan through your employer, your spouse’s employer, or purchased on a state, federal or private market, dental may be included in your benefits.
However, you can also purchase your own private dental insurance separate from medical insurance if your current plan is less than comprehensive or if your medical insurance doesn’t include dental coverage.
Under the Affordable Care Act (ACA), dental insurance plans do not have to cover your dependent children up to the age of 26, like medical plans do. This applies to individual and group dental marketplaces.
However, pediatric dental and vision benefits must be included in or offered as standalone plans as part of the ACA’s “essential health benefits” (EHBs), which must be included in all individual and group health insurance plans.¹
Pediatric dental and vision coverage is required to last through the age 19 years, though individual states may increase this age limit.
If you’re a Medicaid enrollee, states have the flexibility to determine which dental benefits are provided to adult enrollees. While most states provide at least emergency dental services for adults, less than half of the states currently provide full dental coverage.²
States are required to provide dental benefits to children covered by Medicaid and the Children’s Health Insurance Program (CHIP).
You can still qualify for Medicaid if you have a private insurance plan. However, you’ll have to meet Medicaid’s requirements that prove your need for additional discounted medical coverage.³
2. Do you have pre-existing conditions?
Some dental plans don’t cover “pre-existing conditions.”⁴ Pre-existing conditions are usually major issues such as deep fillings that will need crowns.
Replacing a missing tooth could be considered a pre-existing condition if your tooth was lost or extracted before you joined your dental insurance plan. Your plan may also not cover the replacement of crowns, bridges, and dentures unless they’re older than a certain number of years.
When shopping for plans, find out what each carrier considers a pre-existing condition, and determine if the out-of-pocket expenses to cover these conditions will fit into your budget. If not, you may want to keep shopping for a plan that will cover these costs.
3. How much do you want to pay out-of-pocket?
A huge factor in choosing the right private dental insurance plan for you will depend on how much you want to pay out-of-pocket. This includes factors such as monthly premiums, deductibles, co-pays, expenses beyond your plan’s annual limit, and any services which may fall outside of your plan’s coverage.
There are three types of private dental insurance plans, each with different out-of-pocket rates and coverage options.
Three of the most common types of private dental insurance plans include⁵:
Dental Health Maintenance Organization (DHMO)
Dental Preferred Provider Organization (DPPO)
Dental Indemnity Insurance
Limit to which dentists you can see and receive coverage.
Lowest premiums of all dental insurance plans.
Require a deductible.
Rarely have an annual maximum.
No limit on dental services you can have in a year.
Pays the most for services you receive from dentists on your plan’s list.
Pays less for services you receive from dentists outside your plan’s list.
Higher premiums than DHMOs.
Have a maximum amount your plan will pay for your dental services each year.
Dental indemnity insurance
Can go to any dentist and receive coverage.
Highest premiums of any dental insurance plan.
Deductibles and co-payments like DPPOs.
After insurance pays the claim, you pay a bill for the remaining balance.
4. Are you prepared for the waiting period?
Don’t wait to shop for your dental insurance plan until you have a dental emergency, as many private dental plans have a waiting period between three and six months before you can receive coverage for major procedures such as fillings and root canals.
However, most private dental insurance plans will cover preventive care such as routine cleanings and X-rays immediately, with no waiting period. Find out what excluded during your dental plan’s waiting period, and plan accordingly.
Links to external sites are provided for your convenience in locating related information and services. Guardian, its subsidiaries, agents, and employees expressly disclaim any responsibility for and do not maintain, control, recommend, or endorse third-party sites, organizations, products, or services and make no representation as to the completeness, suitability, or quality thereof.
Brought to you by The Guardian Life Insurance Company of America (Guardian), New York, NY. Material discussed is meant for general illustration and/or informational purposes only and it is not to be construed as tax, legal, investment or medical advice.
Explore the latest insights, articles, and guides in our weekly newsletter.
https://www.healthcare.gov/coverage/what-marketplace-plans-cover/ (Last accessed November 2019)
https://www.medicaid.gov/medicaid/benefits/dental/index.html (Last accessed November 2019)
http://thelawdictionary.org/article/can-i-apply-for-medicaid-if-we-already-have-private-health-insurance/ (Last accessed November 2019)
https://www.webmd.com/health-insurance/dental-insurance-overview#1 (Last accessed November 2019)
https://www.thebalance.com/dental-insurance-waiting-period-2645722 (Last accessed November 2019)
Brought to you by The Guardian Life Insurance Company of America (Guardian), New York, NY. Material discussed is meant for general illustration and/or informational purposes only and it is not to be construed as tax, legal, investment or medical advice.(exp.11/21)