Are You Filling the Dental Coverage Gaps?

Groups overlook costly dental coverage gaps that can significantly increase their employees' out-of-pocket costs. 

  

When designing dental benefits for your employees, you have many coverage options. What is the annual maximum, or will endodontics and periodontics be a Basic or Major Service? What about deductibles and orthodontia? These are all important dental benefits, but often other critical coverage is overlooked. 

Let’s look at some costly coverage gaps and the benefits that can save employee out of pocket costs.

Unlimited Covered Dental Benefits 

When considering dental insurance plans for your group, make sure you have a fully insured dental plan with no calendar year benefit maximum and robust coverage, so employees don't run out of covered benefits. 

In recent years researchers have learned more about the connection between good oral health and total body health. Oral health has been linked to diabetes, heart disease, osteoporosis, and even fetal development. Dental benefits are about a lot more than just a great smile. 

That's why ensuring that employees don't run out of covered dental benefits is good healthcare.

Off Renewal Dental Plan Changes

Secondly, it’s important for employees to have access to a plan change benefit, so that they can move to a plan with no annual maximum if they exhaust their annual maximum on their current plan. 

During the plan year employee members enrolled should be able to change from one employer plan to another, one time, off-renewal with no qualifying event required. We should expect this kind of flexibility.

Usual Customary & Reasonable (UCR) Percentile

Do you know at what percentile your clients' UCR dental plans pay out-of-network dentist claims?  Is it the 50th? 70th? 80th? 90th?  And is the UCR based purely on the zip code where the dentist is located?  Or is it a composite UCR taking high and low zip code UCR fees and blending them?  It's important because dental plan members out-of-pocket costs can vary widely depending on the UCR percentile and how it is calculated.  The higher the UCR percentile, the lower the members out-of-pockets costs are generally. 

 

Mexico Dental Network

Complementing our US network is our Mexico Dental Network with contracted providers from Cancun to Guadalajara and all across the US/Mexico border.  Each provider in our Mexico dental network must pass regular equipment and office sterilization audits. This ensures that our members enjoy the same standards of care and patient protections in the U.S. and Mexico.  Our Mexico contracted providers receive some of the highest ratings in both the US and Mexico on these audits.

4 Cleanings Per Calendar Year with Periodontal (Gum) Therapy

Your plan should also cover two regular cleanings and two periodontal maintenance cleanings (four cleanings during a calendar year) to prevent the need for more serious procedures. Those who have previously experienced gingivitis, or periodontitis disease are eligible to have two regular periodontal cleanings in addition to two regular cleanings.  

The U.S. Center for Disease Control reports that pregnant women have a much higher instances of gum disease.*  Pregnant women with diagnosed periodontal disease will also benefit from the additional periodontal maintenance cleanings. 

Full Series Dental X-rays Every 3 Years

Often dental plans only cover full series x-rays every 5 years. Make sure your plan covers full series x-rays every three so that the dentist can catch existing problems sooner, even oral cancer. 

Full mouth dental x-rays (FMX) are an important part of your dental care. These radiographic images give your dentist a complete picture of your mouth, including your teeth, gums, and jaw bones. They allow your dentist to check for potential issues or plan treatment for an existing problem.

Crown and Bridge Replacement Every 5 Years

As you design your dental plan, be sure that your plan covers the replacement of a crown every 5 years. Some dental plans are reducing this benefit to replacement every 10 years---Crowns can cost well over $1,000, the difference between 5 and 10 years can mean thousands of dollars out-of-pocket for employees.

Dental Implant Prosthesis Replacement Every 5 Years

Replacing the implant prosthesis that goes over implant is also costly. Ask your plan benefits administrator to include 5-year replacement for this service, rather than the 10 replacement years many insurance companies offer.

Dental/Partial Replacement Every 5 Years

Just like the services above, your dental plan design should include the 5-year replacement of worn or broken dentures and partial dentures. It is important to avoid benefits that replace these prosthetics for up to 10 years.

Composite (white) Fillings on Molar Teeth

Many employees today want to have white, composite fillings in their mouth instead of silver ones due to health concerns. Unfortunately, many dental insurance plans do not cover composite fillings on back or molar teeth. They say it’s cosmetic. Don’t accept that. Insist that your plan cover composite fillings on molar teeth.

Sealants

Ask that your dental insurance plan covers sealants every 3 years, rather than once per lifetime. This allows you to make sure employees and their dependents can get new sealants after the old ones no longer provide protection.

Periodontal Scaling and Root Planing (Per Quadrant)

While it's far from the most fun way to spend an hour, root scaling and planing is a necessary treatment for advanced gum disease. The early stages are called gingivitis, when bacteria living in the plaque along your gums release toxins. Those toxins trigger an immune response that leads to inflammation.

It’s important to be able to treat each quadrant of the mouth every 12 months if this service is needed. Many dental insurance plans only cover these services every 24-36 months, so be sure to ask before signing up.

You have a choice in designing your dental benefits, so make sure you ask for these important benefits when designing your dental plans.

These dental coverage gaps can add up to thousands of dollars in employee out-of-pocket costs. Employees may decide that a dental plan just isn't worth it, if they fall into these coverage gaps.  It is possible to close the gaps and offer more comprehensive dental coverage. 

Please contact our team members if you'd like to learn more. 

* Center for Disease Control and Prevention website, source:  Content source: Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion