There is a lot of confusion as it relates to dental plans and participating vs. non-participating dentists. Do you choose an in-network or an out-of-network dentist? Which option will best meet both your financial needs, as well as your needs for quality dental care? We have reviewed several online ADA articles in hope that we can clear up some of the confusion and so that you can make dental decisions that are the most beneficial to you and your family in the long run.
What is a Dental Benefit Plan?
Most people refer to the plan that pays for their dental care as insurance, though a dental benefit plan is actually a different type of healthcare plan, says the ADA online article, “What’s the Difference Between Dental Benefits and Dental Insurance?” The article goes on to explain that a dental benefit plan only covers certain costs. It covers some procedures fully, and for others procedures, it only pays a percentage. In addition, sometimes certain procedures recommended by your dentist are not covered at all by a benefit plan.
The challenge occurs when a benefit plan does not cover what your dentist recommends. In these situations, sometimes a patient “settles” for what is covered by their benefit plan instead of receiving what is best in the long-term for the health of their mouth. The ADA article, “Do I Really Need a Dental Plan?” supports this when they say that dental benefit plans are not based on what you need or what the dentist recommends.
Difference Between Participating vs. Non-Participating Dentists:
A dentist who is “in-network” with a dental benefit plan is called a participating dentist and a dentist who is “out-of-network” is a non-participating dentist. The article, “How Does the Dentist I Choose Affect How Much I Pay?” explains that participating dentists have signed a contract with the dental plan carrier in which they have agreed to accept that plan’s set fees as full payment for services. A part of the agreed-upon fee is paid by the dental plan carrier, and you often pay a portion of it with your deductible and co-insurance for the plan. “What Does (And Doesn’t) A Dental Plan Cover?” adds that the amount a plan covers is determined by how much your employer pays into the plan. For individual plans, the terms are listed in the contract.
That said, a large number of dental benefit plans do help to cover dental fees for out-of-network or non-participating dentists. The difference is that benefit plans usually tend to cover less of the out-of-network fees, and the patient is then responsible for whatever costs remain. Of course, the patient always has the option of seeing an out-of-network dentist regardless, as long as they accept responsibility for the full payment of services.
Which Choice is Right for You?
The article, “Does the Dentist I Choose Affect How Much I Pay?” recommends that the choice of a dentist should be based upon whether or not a particular dentist is a fit for your specific dental needs, and not on whether that dentist fits into the requirements of your dental plan. “What Does (And Doesn’t) A Dental Plan Cover” concurs that the least expensive option is not necessarily the healthiest option.
A participating dentist is also not necessarily the most cost-effective option either. The article, “Does the Dentist I Choose Affect How Much I Pay,” supports this when they say that the total costs and premiums that you pay through your benefit plan may actually end up being more than the amount your plan pays. In order to better determine costs, “Do I Really Need a Dental Plan,” recommends that you add up the costs of the plan, which includes the premium, deductible and co-payment, as well as the percentage of treatment costs that you will have to pay out-of-pocket.
So what is the bottom line? The above articles make clear that wise dental health decisions should be based upon your particular dental needs. Finances are also important, but it is incorrect to assume that a participating dentist will necessarily be more cost-effective than a non-participating dentist.
So where do you start when choosing a dentist? Obviously it is important to be aware of your plan’s benefits. Yet, it is equally important to receive referrals from trusted friends and family members who can share their personal experiences about the care that they have received. In other words, do the research and get recommendations. You want a healthy mouth that will last a lifetime…and hopefully a relationship with a dentist that will last just as long.
References:
“Do I Really Need a Dental Plan?” – https://www.mouthhealthy.org/en/dental-care-concerns/do-i-need-a-dental-plan
“Does the Dentist I Choose Affect How Much I Pay?” – https://www.mouthhealthy.org/en/dental-care-concerns/choosing-a-dentist
“What Does (And Doesn’t) A Dental Plan Cover?” – https://www.mouthhealthy.org/en/dental-care-concerns/what-does-my-plan-cover
“What’s the Difference Between Dental Benefits and Dental Insurance?” – https://www.mouthhealthy.org/en/dental-care-concerns/insurance-vs-benefits