Q.  Can I visit any dentist or specialist, or only certain ones?

A.  Dental benefit plans can be categorized by the offered options in selecting a dentist. In an ideal world, a patient would choose a dentist by their individual experience and skill set, but due to individual insurance contracts this is not always an option. The plans that allow you the freedom to choose your own dentist, are the following standard plans: UCR: Usual and Customary Rate plans, fee for service plans, and 80/20 plans. In exchange for lower rates, some plans limit your choice of dentists to a select few. Practices that are willing to cut their fees to provide a different standard of care from other UCR based practices, usually need to attract new patients. They can be new graduates with little experience in clinic dentistry or have the philosophy that a practice's size has priority over the quality of patient care. These two different types of benefit plans are called open and closed panel plans. Other names for the same plans are "in network or out of network", "member or non member", "participating or non-participating".

Open Panel - This type of dental benefits plan allows covered patients to receive care from any dentist. Open panel plans often are described as freedom of choice plans. The patient can dictate who and where they will have their dental work done.

Closed Panel - This type of plan allows covered patients to receive care only from dentists who have signed a contract of participation with the third party Insurance Company. A closed plan is where insurance companies limit your freedom of choice. The third party contracts with a certain percentage of dentists within a particular geographic area. These practices have decided to reduce the costs of dental material and labor, take short cuts, see more patients to compensate for lower fees, and possibly use treatment that is time efficient as opposed to quality oriented.  These practices sign contracts that say they agree to lower fees and alternative procedure that are less expensive to the insurance company, for example an extraction vs. a root canal. Some of the accepted fees are based out of other economic areas, such as the Midwest, which have a lower cost of living.  Be careful to understand where and how your insurance plans work.  Remember, insurance companies are here to make profits not provide dental care.

Preferred Provider Organization (PPO) - This plan allows a particular group of patients to receive dental care from a defined panel of dentists. The participating dentist agrees to charge lower fees to patient's with this plan, providing savings for the plan purchaser (the employer that purchases the plans for their employees). Remember cheaper plans usually provide less coverage. If the patient chooses to see a dentist who is not designated as a "preferred provider," that patient may be required to pay a greater share of the fee-for-service.  This is a way insurance companies entice the patient to think that "I, the patient pay less for the same services, so seeing one of their chosen dentists is better and more cost saving to me and my family." In reality you are paying less and receiving less service or a different quality of service. That is not to say, there are patients that might need to accept a plan such as a PPO, as long as they understand they are receiving cost savings over the quality of service.

Exclusive Provider Organization (PO) - This closed panel plan allows a particular group of patients to receive dental care only from participating dentists. There may be some exceptions for emergency and out-of-area care. If a patient decides to see a dentist which is not listed on the PO panel, charges for service will not be covered by the plan. Because participating dentists are required to offer substantial fee reductions, many dentists elect not to participate in PO-type plans. Under some benefits plans, participating dentists may be salaried employees of the PO. An PO contracts with a limited number of practitioners within a geographic area. Access to necessary specialized care can be restricted. The PO also may limit the amount of services that a patient can receive in a given calendar year.

Dental Maintenance Organization (DOM) and capitation plans-  These plans require you to see their dentist for all services.  The dentists are paid per patient per month whether or not the patient ever makes an appointment in the dental office.  This form of care is counter productive. This entices the dental offices not to encourage patients to make appointments, and in fact you hear of horror stories of patients that call and all the appointment are booked for months.  Seeing patients cost the office time and money, so by discouraging the patients from care, they make more money. It takes large organizations of hundreds if not thousands of practitioners to have high standards, and quality assurance so patient quality and standard can occur. Dr. Conway believes this form of structure is not feasible when providing consistent quality care.

Q. What is a plan deductible and/or annual maximum?

A. A deductible is the dollar amount of covered dental expenses you, the patient, must pay during the year before benefits are paid by your insurance. An annual maximum is the maximum amount your dental plan will pay in benefits during the entire year. Both are generally based on the calendar year, but some are based on the fiscal year. Deductibles and annual maximums apply per covered person. Some families have combined limits. 

Q. Have annual maximums increased in the last 50 years?

A.  Very few insurance companies have increased there maximums to keep up with inflation. Insurance companies had $1,000 to $1,500 maximums in 1960's, and even while homes in the Bay Area have gone from $20,000 to well over $600,000, most Insurances have not changed at all, or at the most doubled in a few cases.