The California Society of Pediatric Dentistry Membership Services Committee has produced the following that may be of value to you when negotiating the intricacies of choosing a health care plan through one of three available avenues: Employer-Sponsored Insurance; Stand-Alone Dental Plans (Exchange or Non-Exchange); or Medi-Cal or CHIP programs.
A special and well deserved thank you goes to CSPD member Dr. Cheryl Willett who, with the able assistance of other committee members, developed the language and content of the following information:
The ACA states that pediatric dental services be available for children 0-19 years of age. You may acquire dental insurance for your child through one of the following ways: Employer-Sponsored Insurance, Stand-Alone Dental Plan (Exchange or Non-Exchange), Medi-Cal or CHIP programs.
On October 1, 2013 Covered California will have the Stand-Alone dental plans available for children 0-19 years. If you are considering dental insurance, it is important to understand the following terms and ask questions before selecting an insurance plan or changing to a new plan. California is currently not offering embedded or bundled dental plans with medical plans. The California Society of Pediatric Dentistry is advocating with Covered California to offer inclusive dental plans for 2015. Watch for changes to come.
There are 3 types of dental insurance plans; Dental Health Maintenance Organization (DHMO), Dental Preferred Provider Organization (DPPO) and Dental Exclusive Provider Organizations (DEPO) that operate similar to medical insurance plans (HMO, PPO). NOT ALL PLAN TYPES ARE AVAILABLE IN ALL AREAS
- DHMO: You have an assigned primary dental provider from a specific network of providers. You may only see a specialist upon referral from this provider. You may have a co-pay, a deductible, and if out of network, you may be responsible for full costs of any dental visit. DHMO often have cheaper premiums, but have limited network providers and services. This is a capitated plan.
- DPPO: You may choose to see any provider from the DPPO network, including specialists. Visits out of network are often covered, but may cost the same or cost more than in-network. You may have a co-insurance based on the type of service and a deductible. DPPO may cost more, but have more freedom to choose providers and access to specialists to provide care for your children. This is a fee-for-service plan which offers greater benefits with contracted providers.
- DEPO: This is a fee-for-service plan in which benefits are only available when services are delivered by contracted providers.
Questions to ask before selecting an insurance:
Does this plan meet the dental needs of my child? What services are offered or limited?
Does it allow 2 exams per year, the types of treatment my child needs (pediatric dentistry, laughing gas, sedation), braces, fillings, etc?
My child and I like our pediatric dentist, are they on the new plan?
Can the network dentists meet the unique needs of your child with medical issues, dental anxiety, young age, etc? Please don’t assume. Many insurance companies offer both DHMO and DPPO options. Be certain to check the provider networks, as most dentists do not accept both. You should be able to search the provider network on the insurance website or call the company directly. Also, call your pediatric dentist’s office and tell them the brand name of the insurance and the type of plan to verify if they accept the plan. If you chose to switch plans, call ahead and ask the network providers if they provide the services your child needs before committing to a plan.
Do the network providers see children? What specialists are in the network?
Before selecting a plan, call the offices on the network and verify if they are comfortable treating children and if so, at what age? Do they offer laughing gas and full service dental care for children and teens from infancy through young adulthood? Are they trained and permitted to perform pediatric sedation services?
What is the monthly cost of the insurance vs. what I will also have to pay out of pocket with co-pays, co- insurance or deductibles?
Often premiums may be higher, but you pay less out-of-pocket for your child’s needs. Check the overall value of the plan for your child’s specific needs.
If I don’t like my new plan, is there a waiting period before I can switch plans again? How do I change plans?
Some plans have waiting periods or only allow changes during open enrollment. Check with the insurance plan or your human resources department about their change process.
Feel free to call our pediatric dental office with any questions or concerns before selecting a new insurance plan.