Health Insurance vs Dental Insurance
Health insurance plans rarely cover dental issues. For that, you need a separate dental insurance policy. Health insurance plans cost more, but provide much more extensive coverage for medical issues. Dental insurance plans are less expensive, but offer less coverage, with limits on how much they pay per year. By understanding the differences, you can find the right combination for your needs.
Health Insurance vs. Dental Insurance: An Overview
Health insurance is a contract between you and the insurer. You pay a premium and the health insurance company pays certain medical costs. This type of coverage focuses on unexpected medical needs, but does not cover most oral health issues.
On the other hand, dental insurance, a more recent innovation, focuses on oral health. A dental policy helps pay for preventive oral health care (such as teeth cleaning, examinations, and X-rays), as well as services such as fillings and root canals. Coverage for non-preventive services tends to be low, as do dental insurance premiums.
“While overlapping in some cost coverage areas, health and dental insurance differ fundamentally in scope and structure,” said Samuel Green, founder and CEO of Blue Insurance. “Health plans encompass a wider range of medical services from hospitals, physicians, labs, and pharmacies, with cost sharing through deductibles, coinsurance, and copays. Dental focuses narrowly on routine oral exams, cleanings, X-rays, fillings, crowns, and tooth extractions tied to set copays or discounts from in-network dentists.”
Health Insurance vs. Dental Insurance: Similarities and Differences
Before we get into the nuts and bolts of how dental insurance and health insurance work, let’s see how certain policy factors compare and differ.
Health Insurance
How Does Health Insurance Work?
“Health insurance covers a portion of costs for approved medical services after members meet annual deductible amounts,” Green explained. “Insurers contract set rates with doctors, facilities, and pharmacies within networks. Remaining costs are paid by coinsurance or fixed dollar copays per service. Total out-of-pocket costs are capped annually.”
Health insurance requires you to pay a monthly premium to the provider. If you have an employer-sponsored policy, your employer may contribute to the premium payment. In return, the insurance company pays some of your medical costs.
Health insurance plans require you to seek care within certain guidelines. For example, a plan might require you to get all your care through a network of participating doctors, hospitals, and specialists.
What Does Health Insurance Cover?
The Affordable Care Act (ACA) established 10 essential health benefits that all health insurance policies must cover:
Ambulatory (outpatient) care
Emergency care
Hospitalization
Laboratory services
Maternity services, including pregnancy and newborn care
Mental health care, including behavioral health and substance abuse treatments
Prescription medications
Preventive and wellness care, including chronic disease management
Rehabilitative and habilitative care, including devices required due to chronic conditions, disabilities, or injuries
Pediatric care, including oral and vision services
What Does Health Insurance Not Cover?
Most health insurance policies do not cover:
Abortion
Ambulance services (except for emergencies or transfers between facilities)
Blood and blood plasma
Commercial weight loss products and programs
Cosmetic procedures
Custodial care
Dental services
Eyeglasses and contact lenses
Hearing aids and hearing examinations
Medical supplies
Sexual enhancement (unless deemed medically necessary)
Vision care
Types of Policies
The most common types of health insurance plans include:
Health Maintenance Organizations (HMOs): HMOs require you to seek medical care from doctors and specialists within a specified network. An HMO will not cover any costs if you obtain medical services outside the network, except for emergencies. These plans cover hospitalization, medical care, and preventive care, and operate within a defined service area. Typically, HMOs charge a fixed copayment for covered medical services, but also require you to meet a deductible and pay coinsurance.
Indemnity Plans: This type of policy allows you to seek medical care from the health provider of your choice. Indemnity plans cover a fixed percentage of costs, and you pay the balance. For instance, a policy might cover 80% of hospital and medical expenses and require you to pay 20%.
Preferred Provider Organizations (PPOs): PPOs also feature a network of health providers, but allow you to seek services outside the network. However, PPOs pay a greater benefit if you seek services within the medical network. They cover hospitalization, medical services, and preventive care.
Deductibles, Coinsurance and Copays
When you use your health insurance benefits, you’ll have to pay numerous costs:
Deductible: The deductible is a specified dollar amount you must pay before your health insurance starts covering costs. For example, if you have a $1,500 deductible, you must pay the first $1,500 in hospital or medical expenses before your insurance policy kicks in. You must reach the deductible every year before receiving benefits.
“High deductible plans exchange lower premiums for higher upfront member medical spending before coverage kicks in. Low deductible options cost more [each month] but lessen per-service charges,” said Green.
Copayments: A copayment is a fixed amount you must pay directly to a health provider when receiving services. For instance, your plan might require you to pay $25 for doctor visits. Oftentimes, plans have different copayments for each type of service.
Coinsurance: Coinsurance is the percentage of costs you must pay for covered services. For example, a policy might require you to pay 20% of hospitalization costs.
Cost
To receive health insurance benefits, you must pay a premium, usually due monthly. For instance, an individual policy might cost $250 per month. If you purchase an individual plan outside of work, you’ll have to pay the entire premium. However, if you buy an employer-sponsored policy, your employer might cover some of the premium costs.
The cost of health insurance for you will depend on your age, where you live, the type of coverage you choose, and your deductible.
Waiting Periods
Some policies impose a waiting period: the amount of time you must wait to receive benefits after enrollment. The ACA stipulates that a waiting period cannot exceed 90 days. “Waiting periods may also apply for pre-existing condition enrollment if continuity of coverage was absent,” Green explained.
Out-of-Pocket Maximums
Health insurance policies feature an annual out-of-pocket maximum. This is the amount of money you must pay annually, after meeting your deductible, before your coverage will pay 100% of covered costs.
Dental Insurance
How Does Dental Insurance Work?
A dental plan is a separate insurance policy from health insurance. As with health insurance, a dental plan requires you to pay certain costs, such as a deductible, premiums, copayments, and coinsurance. “Dental insurance usually works by a patient paying $15-$50 per month in premiums, and then experiencing a cost savings when they receive care with an in-network dentist,” said Dr. Jordan Weber, a dentist at Burlington Dental Center.
Costs and services covered can vary depending on the insurer and plan you pick. Your employer might offer dental insurance, or you can buy coverage from insurer websites or through a government-sponsored marketplace. While the ACA offers subsidies for health insurance, none are available for dental insurance.
What Does Dental Insurance Cover?
Most dental insurance plans cover:
Preventive care: This can include teeth cleanings, examinations, fluoride treatments, and X-rays.
Basic restoration: Tooth extractions and fillings fall into this category.
Major restoration: More serious restorative services can include bridges, crowns, dentures, and root canals.
“Many plans pay 100% of the expenses for preventative care. Major procedures like crowns and bridges are often covered at a lesser percent,” Dr. Weber said.
Some of the best dental insurance companies cover 100% of preventive care, 80% of basic care, and 50% of major care.
What Does Dental Insurance Not Cover?
Usually, dental plans do not cover:
Cosmetic services, like teeth whitening or veneers
Pre-existing conditions, such as missing teeth, that existed prior to enrolling in a dental plan
Implants, unless deemed medically necessary
Types of Policies
Common dental plans include:
HMOs: Like health insurance HMOs, dental HMOs require you to seek services within a network, and do not pay for care outside the network.
PPOs: As with health HMOs, dental PPOs feature a network of dental providers, but allow you to seek care outside the network. While a PPO will pay some out-of-network costs, you must obtain care within the network to receive the maximum benefit. Dental PPOs account for 86% of all U.S. commercial dental insurance policies.
3
Dental Indemnity Plans: This type of dental insurance enables you to seek dental care from the dentist of your choice and pays a percentage of costs. Since dentists do not work within a plan network, they’re reimbursed based on the services they provide.
Dental Savings Plans: This type of coverage is not insurance. With a dental savings plan, participating dentists agree to offer discount prices to plan enrollees on specified services.
“If you have dental insurance, be sure to determine whether or not your preferred dentist is in-network with your insurance,” Dr. Weber said. “While it might not matter, there are many instances where your costs will be higher if your dentist is out-of-network.”
Deductibles, Coinsurance and Copays
Like health insurance policies, dental plans require you to pay deductibles, coinsurance, and copayments. The amount of copayments and the percentage of coinsurance you must pay can vary by provider and plan.
Your plan will specify the amount of coinsurance you must pay, if any. For example, a policy might require you to pay 20% of basic care costs. Likewise, the terms of the policy will specify the amount of copayment you must make for specific services. “Generally, your dentist will provide an estimate of your out-of-pocket expenses, but it is almost impossible to estimate this number accurately due to the nuance and exclusions that are in a typical insurance contract,” Dr. Weber explained.
Cost
As with a health insurance policy, dental plans require you to pay a premium. The amount of premium will depend on the type of plan and provider you choose. Dental insurance can be affordable, with premiums starting at around $15 per month. Just make sure the policy covers enough to make up for the cost of the premiums. Take into consideration the costs of dental procedures without dental insurance, what percentage of those costs are covered by the plan, and what the coverage limit is.
Unlike health insurance, some dental insurance policies impose an annual maximum benefit. For instance, a plan might have an annual maximum of $2,000. Once the insurer has paid that much for your care, you must pay all remaining costs out of pocket.
Waiting periods
Some plans impose a waiting period for new enrollees. For example, you might have to wait six months before you can obtain restorative dental services, like a filling. However, most plans do not impose a waiting period on preventive care.
Out-of-Pocket Maximums
Unfortunately, dental plans do not feature out-of-pocket maximums. That means you’ll have to foot the bill for all services received after meeting your annual coverage maximum. There’s no cap on how much you could spend in a worst-case scenario.
