Signing up for medical insurance benefits is a no-brainer. But what about dental insurance? Does it make sense to pay out?
Generally speaking, it does, if only as a concession to the human condition known as procrastination, or putting off the dental appointment you can’t make today and going, say, the year after tomorrow.
“Having dental insurance makes it easier for people to make the decision to visit the dentist on a more regular basis,” said Jim Marshall, director of the council on dental benefit programs for the American Dental Association. “In a perfect world, a family could readily budget for their oral health needs without a company fringe benefit. But human nature being what it is, it’s easy to put off dental care.”
And though it might sound like so much promotion for dentists, if you don’t take care of your teeth from the outset, you’re likely to pay much more for expensive dental work later–work that is less likely to be covered by insurance.
Although many dental plans now pay 100 percent of preventive services on a set schedule, they often will pay 80 percent of the charge should you need an amalgam (filling) restoration or a crown, with the patient covering the balance. For more major dental work such as dentures, the plan is likely to pay just 50 percent, with the patient covering the rest.
If your mouth needs a lot of work, you need to be aware of the cost of paying out of pocket. A filling can run from $90 to $200 or more, depending on whether the filling is silver, tooth-colored or a porcelain inlay (which is the most expensive and excluded from almost every dental plan). If you’ve really let your dental health deteriorate, you might pay in the range of $3,500 for a series of deep cleanings, root canals and crowns. And for major reconstruction, count on budgeting as much as $20,000 to $30,000.
Is a dental plan–and regular visits to the dentist’s office–beginning to sound a little better now?
Dental plans do help encourage people to get regular dental attention by paying for semi-annual checkups and cleaning, but they can discourage patients most in need from seeing the dentist enough. For example, someone with problem gums is likely to be on a three-month “recall.” Most insurance companies will pay only for cleanings every six months, and won’t even budge a day or two.
“It’s absurd,” said Dr. Todd Molis, a dentist in Burr Ridge. “Why isn’t it up to the treating practitioner to determine how often a patient’s gums are treated?”
Molis said six months or even a year is a reasonable cleaning schedule for some patients, but others must make the decision to pay an uncovered $69 at his office for a cleaning every three months. He uses a cutting-edge screening system to show patients on the spot how much bacterial activity is in their mouths and why the extra money might save bigger headaches–and toothaches–in the future. If you don’t get the appropriate cleanings, a “crash” program to save your teeth and gums can cost $1,000 and gum surgery runs about $6,000. Yearly limits on coverage, which range from $1,000 to $2,500 can be tapped in a hurry. And some plans exclude periodontal surgery.
“I tell all of my patients the same thing,” said Molis. “Insurance companies are not in the business of paying out claims. Don’t let an insurance company dictate your oral care.”
The expense of neglect can be equally high for employers. An estimated 20.5 million workdays are lost each year while people care for their dental problems. That’s a lot of people with toothaches and post-root canal haze.
Some 120 million people in the United States now carry dental insurance benefits through their employers. Indemnity-type dental benefits emerged in the early 1970s and continue to be the dominant form of insurance offered.
An indemnity plan pays the dentist on a fee-for-service basis. The patient or his employer pays a monthly premium to an insurance carrier, which then reimburses the dentist. Such plans often have a predetermined deductible that the patient must pay before the insurance coverage kicks in. A typical deductible amount is $50, although routine preventive costs are typically fully covered. In the ’80s and ’90s, some dental coverage shifted to managed care, said Marshall. In these plans, the dentist typically is paid on a per person basis rather than for specific treatments, and patients may pay co-payments of $10 or $20 for each visit.
“HMO plans limit the dentists you can see,” said Dr. Robert E. Dennison, CEO of Delta Dental of Illinois, an insurance carrier. “You get a cost savings if you see a dentist listed in the plan, but you won’t gain the cost savings if you go to a dentist outside of the network.”
About 25 percent of people with dental insurance have managed care plans. Patients have a bit more flexibility through a PPO (preferred provider organization) plan if they choose to see an out-of-network dentist, said Dennison. “You may have a higher co-payment, but the same procedures are typically covered.”
Currently, the American Dental Association is promoting a dental plan concept called “direct reimbursement,” which gives employers the opportunity to self-fund a dental benefit without utilizing a third party insurance company to underwrite it.
“This allows the employer to set its own budget and reimburse employees’ dental services directly,” said Marshall. “You just bring in a paper from the dentist and the company pays it. It’s much simpler. It lets the patient and dentist decide what kind of services they want and when. It also allows the patient to stay with a particular dentist or go to another one if he wants to. We think this is good for the consumer.”
In any plan, the individual still must be motivated to make the appointments. Dental anxiety tends to be more associated with urgent pain (the tooth hurts, fix it please) or painful memories (no child or adult tends to forget the sound of a dentist’s drill). Today’s dental insurance plans are designed with an emphasis on preventive dental services, which tend not to hurt much, if at all.
“The concept is that dental disease is essentially entirely preventable,” said Marshall. “With regular daily oral hygiene by the individual and regular professional care, most major dental services and disease can be minimized.”
With that in mind, most insurance plans now pay 100 percent of preventive services such as semi-annual oral exams, semi-annual dental cleanings and fluoride treatments, a complete set of annual X-rays, bite-wing X-rays to look for cavaties twice a year and dental sealants for children.
Crooked teeth are getting more attention as well. Many insurance plans now cover orthodontics–both for children and adults–usually giving the insured person a maximum annual allowance of from $1,000 to $2,000 with a lifetime allowance of perhaps $2,000 to $3,000. While that may not foot the whole bill, it helps.
So what’s not covered? Dental implants, said Marshall, a newer technology to replace lost teeth.
“This involves implanting an anchoring device into the jaw, onto which is anchored a crown or a bridge or denture,” he said. “Implants aren’t experimental any longer, but they’re costly. They’re mostly excluded because of the cost.”
That could change in the future. “We do see the Baby Boom generation being one that expects dental benefit insurance for themselves and their children. They’re keeping their teeth throughout life, unlike their parents or grandparents, who expected to lose most of their teeth in old age.”
Should your employer offer a choice of dental plans, it would be wise to contact your dentist as well as neighbors and friends to help you determine what choice will work best for you. It is important to pay attention to the plan’s limitations or exclusions. These may include limits on the number of procedures allowed, the total dollar amount covered and possible exclusions on major dental work such as surgery for periodontal disease, orthodontics, gold or crown restorations, dental implants or repairs to dentures and bridges.
You also should determine whether you or your dental plan ultimately is in charge of dental treatment decisions. Some plans require that the dentist use the least expensive treatment available. If you prefer something better, you’ll have to pay for it yourself. For example, if you want a tooth-colored or porcelain filling, the plan may pay only for the cost of a silver filling and you will have to pay any cost above and beyond that for the more costly filling. Coverage for emergency services may be restricted as well.
For more information about specific issues regarding dental plans, contact the American Dental Association in Chicago (800-621-8099) for consumer information.
No matter what dental benefits you select, it is important that you use them.
“It’s like taking care of your car,” said Molis. “If you never change the oil or fix the little things, then soon enough you will have a major problem.”
DENTAL HEALTH DOES A BODY GOOD
If your gums are inflamed and you’ve ignored the dentist for years, you may be at risk for bigger problems than a long day in the dentist’s chair.
Heart attacks, strokes, pre-term and low-birthweight babies and serious infections among diabetics all have been scientifically linked to gum disease, or periodontitis, said Dr. Jack Caton, professor at the University of Rochester’s Eastman Dental Center and president of the American Academy of Periodontology.
“The data remains strong that there are links between systemic disease and periodontitis,” he said. “The most important concerns are heart attacks and strokes.”
In the case of heart attacks, there is the potential bacteria to pass from the mouth into the bloodstream. The bacteria lodges in the coronary arteries, helping to induce the formation of atherosclerotic plaque that blocks the arteries and breaks off, causing a stroke or heart attack.
“Researchers are finding a correlation between inflamed gums and what occurs in the coronary arteries,” said Dr. Christine Lawless, a cardiologist and director of the heart failure program at Loyola University Medical Center, Maywood. “We think that in the coronary arteries, people not only get a buildup of cholesterol, but they also get an inflammation of certain white blood cells that are involved in the creation of atherosclerotic plaque. The reason these white blood cells are proliferating is because of possible infection.”
Babies can bear the brunt of a gum infection. Studies show women with periodontitis have seven times the chance of delivering a pre-term, low-birthweight baby.
“The body’s defense against this infection is to produce all kinds of soluble substances to wall off and fight the infection so it doesn’t cause brain, lung or kidney abscesses,” said Caton in explaining the link. “These substances travel through the blood stream to all parts of the body. Some of these are the same chemicals used by doctors to trigger childbirth in women who need to be induced.”
Although women often neglect dental care during pregnancy, Caton said it is important for them to pay even more attention to their daily oral hygiene and to have their teeth cleaned often. The American Dental Association says pregnant women might be more susceptible to teeth and gum problems, so regular care is recommended–though X-rays are not advised.
Diabetics need to pay attention to their teeth as well. A report in the September issue of the Journal of the American Dental Association found that diabetics lack important knowledge about the oral health complications of their disease. Gum disease can throws off a diabetic’s sugar metabolism. By clearing up infections in the mouth, diabetics can better maintain proper levels of blood glucose.
“In the same way,” said Caton, “people with diabetes are much more susceptible to infections. Uncontrolled diabetics have higher incidences and severity of periodontal disease.”
There’s more.
The incidence of upper respiratory infections is twice the average in patients who have periodontitis. And smokers are five times more likely to have periodontitis than non-smokers.
