Types of Dental Plans/Benefit Details
Types of Dental Plans
Payment given to a doctor for providing services to a certain number of people. The amount paid depends on the number of patients.
Health Maintenance Organization is referred to as an HMO. A type of dental plan where the doctors agree to take a lesser fee for its members. HMO plans only cover if the patient sees the right HMO doctor.
Exclusive Provider Organization is also referred to as an EPO. Similar to an HMO. Lower out of pocket expense than a PPO for a patient, and no payment is made by plan if patient sees an out of EPO network doctor.
Preferred Provider Organization is also referred to as a PPO. A reduced fee-for-service plan that allows enrollees to visit any dentist, but encourages them to visit PPO network dentists to minimize out-of-pocket expenses. Enrollees usually pay less when visiting a PPO dentist.
Compensation paid to dentists based on an amount per service. A fee-for-service plan generally permits enrollees to freely select a network or non-contracted dentist to provide the service.
Government Funded Plans
Areas of Coverage
The areas of coverage listed in the categories below does not include a full and comprehensive list of all services within that category.
The numbers written before the coverage area indicate the dental code numbers where that procedure can be found in a comprehensive list.
- D0100-D0999 Diagnostic/D1000-D1999 Preventive
- D2000-D2999 Restorative
- D3000-D3999 Endodontics
- D4000-D4999 Periodontics
- D5000-D5899 Prosthodontics (removable)/D6200-D6999 Prosthodontics (fixed)
- D5900-D5999 Maxillofacial Prosthetics
- D6000-D6199 Implant Services
- D7000-D7999 Oral & Maxillofacial Surgery
- D8000-D8999 Orthodontic
- D9000-D9999 Adjunctive General Services
D5000-D5899 Prosthodontics (removable)
D6200-D6999 Prosthodontics (fixed)
Areas of Coverage for Payment Purposes
Most plans cover 100% of preventive care and apply co-payments, either as a dollar amount (DHMOs) or as a percentage (DPPOs and Dental Indemnity/ or Traditional Insurance) to other levels of care. Preventative care usually includes periodic oral evaluations, x-rays and sealants. (NOTE: Sealants may be limited to certain age groups.)
Office visits, extractions, fillings, root canals, and periodontal treatment for gum disease, are typically covered at a lower percentage amount, for instance 80% (sometimes 60%), or with lower dollar co-payments in the case of a DHMO.
Crowns, bridges, inlays, and dentures are usually covered at the lowest percentage, such as 50% or a higher dollar co-payment in the case of a DHMO. Root canals are also sometimes covered in this category rather than as a Basic procedure, so check your coverage. Some carriers now offer coverage for implants under this category of coverage.
Did you know?
Just under half of dental PPOs, the predominant dental product in the market, have a maximum annual benefit above $1500—half are less than $1500. Deductibles for these products are usually between $50 and $100.
Need more help with procedure codes and things to know when submitting claims?
We LOVE Coding With Confidence by Charles Blair, D.D.S. Our other favorites are the CDT: Dental Procedure Codes and the CDT Companion Guides put out by the ADA each year. We recommend having those at your front office to ensure proper claim submissions.