What is Dental coverage?

The Dental benefit covers all or a portion of certificates dental work. Dental is considered a highly desirable and relatively low risk benefit, due to most certificates utilizing the benefit at least once a year. The claims themselves are predominantly low to mid cost and the high utilization makes the claims fairly stable and predictable.

The dental procedures that are covered vary greatly depending on the levels of Dental covered under the plan. 

Dental Levels

Dental is typically split into four levels:

• Basic Restorative:  This covers diagnostic and preventative treatments, such as cleanings, scaling of teeth, dental examinations, x-rays, oral hygiene, fillings and tooth extractions.
  
• Periodontic-Endodontic: Includes periodontic services to treat the bone and gum around the tooth and endodontic services.
• Major Restorative: This covers crowns, dentures, inlays, onlays and bridgework. Other more extensive dental may also be covered, including major dental surgery and root canals.
  
• Orthodontic: This covers appliances such as braces, wires, spacers and other dental aids used to straighten teeth or correct other problems. Pre-approval is often required before proceeding with Orthodontic work. Orthodontics often has a higher co-insurance and a lifetime maximum (as opposed to an annual maximum). One other choice to be made is whether or not to extend Orthodontic coverage to adults or only to child dependants. 

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Dental components:

There are many components of the Dental benefit. The following is not intended to be an exhaustive list, rather these are the most common components:

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Funding model:

Due to it’s relatively low risk of extremely high claims and fairly stable experience, Dental is often a strong candidate for the Administrative Services Only (ASO) funding model. ASO means that the client takes on the full risk of claims payment themselves and pays the insurance carrier a small administration fee per claim. This mitigates the risk of the policy owner overpaying for their Dental benefit, for example if Dental claims were lower than anticipated and were considerably less than the Dental premium paid. However it also means the client is fully responsible if Dental claims are higher than anticipated.

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Scaling Units

Scaling units are a measurement of time spent scaling the teeth to remove plaque. These units are measured in 15 minute increments. When employees go to the dentist for their regularly scheduled cleanings, this is typically when scaling units are used, with multiple scaling units charged per visit (typically 2-3, depending on how long was spent scaling the teeth).

Scaling units often have their own maximum as part of the plan design, for example 12 scaling units per period. It is important for employees to know the scaling units maximum on their plan, and also how many scaling units the dentist is charging per visit, to ensure they aren’t left with an expensive out of pocket charge.

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Recall period:

This determines the length of time required between regularly scheduled dental visits. The most common recall period is 6 months, but 9 or 12 months are also available. Longer recall periods reduce the cost of the dental benefit.

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Coinsurance:

Coinsurance defines what % of a dental claim the insurance carrier will pay. Lower coinsurances leave the employees covering more of the cost, which reduces the dental claims experience and lowers the dental rates. Note that unlike deductibles, coinsurance continues to be paid for every dental claim, there is no annual limit on the out of pocket expenses for the employee.

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Deductible:

This works the same way as other insurance deductibles, it is an annual out of pocket expense that the employee must satisfy before a dental claim is paid. Deductibles are different for single and family certs, for example the single deductible may be $50 and the family deductible may be $100. Deductibles are reset every 12 months.

For groups switching carriers late in the calendar year it is often worth getting a report of which employees have satisfied their deductibles, or if such a report is not available asking the new carrier to waive deductibles for all employees for the remainder of the year. This ensures employees are not being penalized by a change in carriers.

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Maximum:

The maximum $ amount that will be paid out over a 12 month period. There are separate maximums for each level of dental, with options to combine level 3 dental with levels 1&2 to better control costs. Level 4 dental has a lifetime maximum as opposed to an annual max. There may also be a choice for the maximum to be calculated per certificate (ie employee and all dependants combined) or per insured (each family member gets their own maximum).

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Waiting Period:

The Dental waiting period determines the length of time a new employee must wait before their dental coverage becomes activate. Longer waiting periods can be used in high turnover classes to help reduce the risk of new employees gaining employment solely to utilize the dental benefit. Note however that longer waiting periods can make things difficult for new employees that had dental coverage at their previous employer and now find themselves without dental coverage for an extended period of time.

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Termination Age:

The age at which the Dental benefits cease to be paid. 75 is the standard Dental term age, but several carriers will allow Dental coverage up to age 85 or even beyond.