Op-ed by D. Kenton Henry

“Is dental insurance really worth the premium I pay?” is one question I am asked frequently. It is often followed, almost instantly, by―”Or am I simply paying for my dental work on a time a payment plan?”

My answer to both questions is a definitive, “Maybe.”

If you, as the majority do, have dental insurance through your employer, that employer is subsidizing all or part of your premium. This convenience makes for a solution to the equation, more favorable to you. In contrast―if you are self-employed, retired, or otherwise personally have to pay the full amount of a dental insurance premium―the opposite may be true. That is unless you take some straightforward advice, I am about to provide. If you do not, you most likely will only be spreading your cost for dental work over time. Even worse, dental insurance could prove to be a “loss item” in that you will have paid more in premiums than you will ever receive in benefits.

Short of taking a long drive and crossing the Rio Grande into Mexico to obtain your dental work, what can you do to offset the cost of say, a dental implant, which, on this side of the border, is going to run from $3,500 to $7,000?

Let me preface this by with a premise or three:

#1) With no insurance company is “the sky the limit”. I’m referring to the fee they are going to pay a dentist for a particular dental procedure. For example, no insurance company is going to accept a fee of $10,000 for a single porcelain crown. Not even their share of that cost, which is typically 50%. So what is the limit of a fee the insurance company will cover? That limit must be contractually defined, and the limit most insurance companies abide by is, “reasonable and customary” or “reasonable, usual, and customary”. These are empirical standards an insurance company uses to determine whether to pay a fee. Or how much of a fee to pay. If the dentist charges the general prevailing rate in your geographical area, they are going to pay the portion for which they are contractually obligated. Basically, it’s the average charged in your neighborhood. You will be charged more in Beverly Hills, California and less in Brenham, Texas “where the cows think it’s heaven”. Additionally, if “usual” is part of the definition, the fee has to be in line with what this particular dentist charges for a particular procedure. If fee is disproportionate either, or, both, ways―the maximum amount paid by the insurance company will be the limit set in their fee schedule.

#2) A dental insurance plan is either a provider network plan or a non-network plan. If it is a network plan, it is usually either a Dental Preferred Provider Organization (DPPO) Plan or a Dental Health Maintenance Organization (DHMO) Plan. If it is the first, you may go outside the network of dentists with which the insurance company has contracted but will most likely pay a higher cost for doing so. With the latter, you must remain within the network of dentists or, you have no insurance coverage whatsoever. For either of these options, you pay a lower premium than if you purchase a non-network or “any dentist” plan. The reason is that you agree to utilize or, at least, consider utilizing a dentist with whom the insurance company has contracted to charge you a lower fee than they would without the contract. This limits the insurance companies losses and brings increased traffic to the dentist.

#3) This is perhaps the most important part. If you purchase a non-network dental insurance plan, you can, almost, be assured you will be charged more than the insurance company deems acceptable. Additionally, you will be responsible for any dollar amount above their “reasonable and customary” rate. However, if you purchase a network plan, and go within the network of dentists, you will not be held responsible for any “excess” charges. Any charges above the reasonable and customary rate, the dentist will be forced to “write off”. In this situation, you will never have to worry about a surprise bill or claim. If a policy says your share of the bill is 20% or 50%, it will be that and not 20% or 50% plus any excess charges.

Assuming you accept you must acquire a network plan, in order to limit you own losses and surprise dental bills, the challenge becomes, “How do you find a quality dentist willing to accept a lower fee for treating you?” The typical HMO dental provider is typically someone straight out of dental school or who otherwise needs to build their patient base. In return for sending patients their way, the dentist is willing to accept a meaningfully lower fee. If the dentist is a PPO provider, they may have been in business longer, have more experience, and perhaps a reputation for having better skills. But they are willing to accept a somewhat lower fee in return from the many employees a large company may send their way. The dentist who isn’t willing to participate in any network apparently feels they have all the clients they need. That or their reputation is so great it will draw all the traffic they require.

The problem is, unlike a large oil company, as an individual, or family, you don’t bring enough “volume” to the table to bargain for a lower dental fee. At least not by yourself. Therefore, you have to identify and purchase your dental insurance from an insurance company which has the reputation of insuring a large number of employees of that oil company. As well as having a reputation for paying their claims in a timely and efficient manner. A manner such that the dentist wants to be contracted with them. From your standpoint, you want that insurance company to have a reputation for the same when it comes to you and not have to worry about claim disputes.

Another challenge is, at $6,000 for a dental implant, your dental benefit may not go too far. Secondly, does your insurance plan cover implants in the first place? Again, the sky is not the limit. The average dental plan covers a maximum of $1,000 of dental treatment per year. You can pay a higher premium for incremental benefits up to a maximum of $5,000. But a policy which pays that much in year one would cost a fortune and there is typically a twelve-month wait for major dental work to be covered. As such, you may want to find a plan which increases to that limit with each passing year and is available at what you consider a reasonable cost.

How do you find a dental policy which does not subject you to “excess” costs; allows you to see a highly skilled dentist, utilizing the latest technology and performing the most advanced form of treatment; all at a competitive premium? And this from a company which pays the claims they are contractually obligated to pay while doing so in a timely fashion?

This is where I, and my thirty-three years experience in the medical and dental insurance business, come in. My experience as a patient and consumer is even longer. After being in braces for eight years, I had all my front teeth knocked out in an auto accident when they impacted the steering wheel. I was wearing a seat belt, which saved my life, but not a shoulder strap. I’ve had to have the dental work replaced on three occasions since that senior year of high school. This year, I proceeded with what will be one double crown and, ultimately, two implants. (Ouch, is right!) I was not willing to accept this type of work from a mediocre dentist―and certainly did not care to pay cash for it! So I found a policy, issued by a large, financially sound insurance company, with a reputation for excellent customer and claim service. Then I found a policy which ultimately pays the maximum $5,000 annual benefit. In order for it to be affordable to me, it started, December 1 of 2018, at a calendar year benefit of $1,500―immediately went to $2,500 January 1, of this year―and will go to a $5,000 benefit this coming January. So I only paid for a $1,500 benefit for one month before it jumped to a $2,500 benefit! During this year I acquired the double porcelain crown and the bone graft and post for one dental implant. In 2020, I will have the crown for the implant post attached, when my calendar year benefit is $5,000. The second implant is optional, and I will probably have that work done in 2021 when my benefit remains $5K.

Once I knew what company to go with, the final step in selecting my dental insurance policy required finding the right dentist. I reviewed the insurance company’s list of network providers and researched the dentist’s reputation via credentials and reviews. I won’t belabor that but, suffice it to say, I found a dentist who met my requirements. He is very conveniently located relative to any resident of The Woodlands or Spring and, in my opinion, is well worth going to if you reside anywhere in Montgomery County or Northwest Harris County. He utilizes the latest technology, has a great and skilled staff, and a decent, very professional, if not overly effusive, chairside manner.*

In summation, in order to make dental insurance worth your while, you need to:

1) accept you need to acquire a “network provider” dental plan

2) find a policy which pays a reasonable benefit based on your foreseeable need, at an affordable premium and

3) allows you to go to a skilled dentist convenient to you

I have done all the homework for you. For over three decades, I have specialized in medical, Medicare-related, and dental insurance. I provide objective quotes from established “A” rated companies and quality customer service. Among the companies I represent are Aetna, Ameritas, Anthem, BlueCross BlueShield, Cigna, Delta Dental, Humana, and UnitedHealthcare. I am located in the heart of The Woodlands and am accessible from my websites Allplanhealthinsurance.com and TheWoodlandsTXHealthInsurance.com. You may also feel free to contact me at my numbers below.

I look forward to working with and assisting you in acquiring any of the above referenced products.

D. “Kenton” Henry                                                                                                               Editor, Agent, Broker Office: 281-367-6565                                                           Text my cell @ 713-907-7984                          http://TheWoodlandsTXHealthInsurance.com                              http://Allplanhealthinsurance.com                                   http://HealthandMedicareInsurance.com https://linkedin.com/in/kentonhenryinsuranceconsultant

*(Neither I nor my agency and websites are affiliated in any way with a particular dentist or dental office. Neither do we receive compensation from the same for any recommendation we may make.)