New York Dental Plans

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Traditional New York dental insurance is often perceived as the best way to pay for dental expenses. And while dental insurance is an excellent option when sponsored by your employer, it may not be very cost effective when you are paying for it.

Most individual dental insurance plans require you to satisfy waiting periods and deductibles before having major and sometimes even minor restorative work done. Discount dental plans help make maintaining good oral health a lot more affordable. And, with no waiting periods or complicated coverage procedures, dental discount plans are about as simple as you can get.

How do New York discount dental plans work? As we become aware about our oral health, there has been a demand for affordable dental care. Discount dental plans are the newest option for those without coverage. These dental discount plans are much cheaper than traditional dental insurance, and also offer almost equal coverage for all dental work, even cosmetic procedures not covered by standard indemnity dental plans.

The catch is that dental discount plans are not really insurance at all. They work more like club memberships, where the cost of membership (your "premium") earns a steep discount on any club service (dental work) you buy. The discount normally applies to all dental office services performed by an approved "plan" dentist, but no procedure is covered completely.

What are the ins and outs of discount dental plans? When it comes to dental discount plans, the good news is afford ability, breadth of services, and immediate coverage. The bad news is greater financial risk and responsibility on your part.

Although the monthly cost of most discount dental plans is very low compared to the price of a traditional dental insurance or indemnity insurance policy, there's more allover financial risk with a dental discount plan. No care is totally covered, so an expensive procedure will mean a big out-of-pocket expense, even with the dental plan. And even when undergoing a low-cost service (like cleaning), you'll still be expected to pick up a part of the cost.

However, on the plus side, discount dental plans are effective immediately - so are many procedures you need now will be covered as soon as you buy the dental discount plan. Traditional indemnity and/or insurance dental plans usually impose a waiting period of between 6 and 18 months for any major procedure. The last "pro" is that all good dental discount plans should come with a money-back guarantee.

New York Indemnity Plans

This type of New York dental plan pays the dental office (dentist) on a traditional fee-for-service basis. A monthly premium is paid by the client and/or the employer to an insurance company, which then reimburses the dental office (dentist) for the services rendered. An insurance company usually pays between 50% - 80% of the dental office (dentist) fees for a covered procedures; the remaining 20% - 50% is paid by the client.

These plans often have a pre-determined or set deductible amount which varies from plan to plan. Indemnity plans also can limit the amount of services covered within a given year and pay the dentist based on a variety of fee schedules. Some typical features of these plans:

  • High deductibles before coverage begins (well-designed plans don't apply the deductible to preventive services)

  • Probationary periods on certain procedures that last up to a year

  • Annual dollar limit on benefits

  • Chose your own dentist

  • Your average monthly cost: $15 to $25

  • Companies selling these plans are regulated by state insurance departments.

New York Dental HMOs

These New York insurance plans, also known as "capitation plans," operate like their medical HMO cousins. This type of dental plan provides a comprehensive dental care to enrolled patients through designated provider office (dentist). A Dental Health Maintenance Organization (DHMO) is a common example of a capitation plan. The dentist is paid on a per capita (per person) basis rather than for actual treatment provided.

Participating dentists receive a fixes monthly fee based on the number of patients assigned to the office. In addition to premiums, client co-payments may be required for each visit. Some typical features of these plans:

  • Monthly premiums (some require you to prepay a year's worth)

  • Co-payments for office visits

  • Free preventive or routine care

  • You must select from an approved network of dentists

  • May have an initial enrollment fee

  • Annual dollar cap

  • Your average monthly cost: $5 to $15

  • Companies selling these plans are regulated by state insurance departments.

New York Preferred Provider Organizations

Another true New York insurance plan, a Preferred provider organizations ( PPO) falls somewhere between an indemnity plan and a dental HMO. This plan allows a particular group of patients to receive dental care from a defined panel of dentists. The participating dentist agrees to charge less than usual fees to this specific patient base, providing savings for the plan purchaser.

If the patient chooses to see a dentist who is not designated as a "preferred provider," that patient may be required to pay a greater share of the fee-for-service.  A group of dentists agrees to provide services at a deeply discounted rate, giving you substantial savings as long as you stay in their network. Unlike the more restrictive DHMO, though, you can go out of network and still receive some benefits. Some typical features of these plans:

  • Monthly premiums

  • Annual dollar cap

  • You must stay within the approved network of dentists or pay higher deductibles and co-payments

  • Your average monthly cost: $20-25

  • Companies selling these plans are regulated by state insurance departments.

New York Dental Discount

This type of New York dental plan is not insurance. The managing organizations have negotiated with local dental offices to establish a set price for a particular dental procedure and offer deep discounts (some up to 70%) off the regular ADA pricing code.

This plan has several advantages over traditional dental insurance plans, namely, there are no exclusions for pre-existing conditions. This allows a patient to receive immediate coverage for work without meeting any waiting period requirements.

New York Direct Reimbursement Plans

A New York dental care plan now coming into vogue is the direct reimbursement plan. This is a self-funded benefit plan not insurance in which an employer pays for dental care with its own funds, rather than paying premiums to an insurance company or third-party administrator.

You, the patient, pay the full amount directly to the dentist, then get a receipt detailing services rendered and the cost, which you show to your employer. The employer reimburses you for part or all of the dental costs, depending on your specific benefits.

Your company might reimburse 100 percent of your first $100 of dental expenses and then 80 percent of the next $500, and 50 percent of the next $2,000, with a total annual maximum benefit of $1,500. Or it might reimburse only 50 percent of your first $1,000, resulting in a $500 yearly cap.

Some typical features of a direct reimbursement plan:

  • Neither you nor your employer pay monthly premiums

  • Freedom to choose any dentist

  • Typical employer cost: depends on the number of employees and benefit caps

  • Benefits usually capped at $500 to $2,000 annually.

Dental care is quite different than medical care. Major illness can strike at any time and the costs can be enormous. Most dental disease is preventable and treatment is predictable. Regular checkups and professional cleaning can help maintain your oral health and so dental benefits are written to encourage patients to seek preventative care in order to prevent more serious dental problems.

What do you look for in choosing a New York plan?

Does the New York plan give you the freedom to choose your own dentist or are you restricted to a panel of dentists selected by the insurance company? If you have a family dentist with whom you are satisfied, consider the effects changing dentists will have on the quality or quantity of care you receive. Because regular visits to the dentist reduce the likelihood of developing serious dental disease, it's best to have and maintain an established relationship with a dentist you trust

Who controls treatment decisions--you and your dentist or the dental plan? Many plans require dentists to follow treatment plans that rely on a Least Expensive Alternative Treatment (LEAT) approach. If there are multiple treatment options for a specific condition, the plan will pay for the less expensive treatment option.

If you choose a treatment option that may better suit your individual needs and your long-term oral health, you will be responsible for paying the difference in costs. It's important to know who makes the treatment decisions under your plan. These cost control measures may have an impact on the quality of care you'll receive.

Does the plan cover diagnostic, preventive and emergency services? If so, to what extent? Most dental plans provide coverage for selected diagnostic services, preventive care and emergency treatment that are basic for maintaining good oral health.

But the extent or frequency of the services covered by some plans may be limited. Depending upon your individual oral health needs, you may be required to pay the dentist directly for a portion of this basic care. Find out how much treatment is allowed in any given year without cost to you, and how much you will have to pay for yourself.

  • Initial Oral Examination----once per dentist

  • Recall Examinations----twice per year

  • Complete x-ray survey----once every three years

  • Cavity-detecting bite-wing x-rays----once per year

  • Prophylaxis or teeth cleaning----twice per year

  • Topical Fluoride treatment----twice per year

  • Sealants----for those under age 18

What routine corrective treatment is covered by the dental plan? What share of the costs will be yours? While preventive care lessens the risk of serious dental disease, additional treatment may be required to ensure optimal health. A broad range of treatment can be defined as routine. Most plans cover 70 percent to 80 percent of such treatment. Patients are responsible for the remaining costs. Examples of routine care include:

  • Restorative care - amalgam and composite resin fillings and stainless steel crowns on primary teeth

  • Endodontics - treatment of root canals and removal of tooth nerves

  • Oral Surgery - tooth removal (not including bony impaction) and minor surgical procedures such as tissue biopsy and drainage of minor oral infections.

  • Periodontics - treatment of uncomplicated periodontal disease including scaling, root planning and management of acute infections or lesions

  • Prosthodontics--repair and/or relining or reseating of existing dentures and bridges.

What major New York dental care is covered by the plan? What percentage of these costs will you be required to pay? Since dental benefits encourage you to get preventive care, which often eliminates the need for major dental work, most plans are not generous when it comes to paying for major dental work, most plans cover less than 50 percent of the cost of major treatment.

Most plans limit the benefits--both in number of procedures and dollar amount--that are covered in a given year. Be aware of these restrictions when choosing your plan and as you and your dentist develop treatment best suited for you. Major dental care includes:

  • Restorative care--gold restorations and individual crowns

  • Oral Surgery--removal of impacted teeth and complex oral surgery procedures.

  • Periodontics--treatment of complicated periodontal disease requiring surgery involving bones, underlying tissues or bone grafts.

  • Orthodontics--treatment including retainers, braces and/or diagnostic materials.

  • Dental Implants--either surgical placement or restoration

  • Prosthodontics--fixed bridges, partial dentures and removable or fixed dentures.

Will the plan allow referrals to specialists? Will my dentist and I be able to choose the specialist? Some plans limit referrals to specialists. Your dentist may be required to refer you to a limited selection of specialists who have contracted with the plan's third party. You also may be required to get permission from the plan administrator before being referred to a specialist. If you choose a plan with these limitations, make sure qualified specialists are available in your area. Look for a plan with a broad selection of different types of specialists.

If you have children, you may prefer a plan that allows a pediatric dentist to be your child's primary care dentist. Since specialized treatment is generally more costly than routine care, some plans discourage the use of specialists. While many general practitioners are qualified to perform some specialized services, complex procedures often require the skills of a dentist with special training. Discuss the options with your dentist before deciding who is best qualified to deliver treatment.

Can you see the dentist when you need to, and schedule appointment times convenient for you? Dentists participating in closed panel or capitation plans may have select hours to see plan patients. They may schedule appointments for these patients on given days, or at specified hours of the day, restricting your access.

Some dentist's fees for seeing you on weekends or during emergencies are high than those the plan allows. You may be required to pay additional costs yourself. If you select these types of plans, have a clear understanding of your dentist's policies as well as the plan's dentist-to-patient ratio. It's the best way to ensure your access to care is not unduly restricted and that you are not surprised by higher fees the plan does not cover.

Insurance companies do their best to ensure that their policyholders understand their plans and benefits, but it is up to an individual to make sure that they are making informed choices. The differences in the various plans you can choose from are:

  • The type of third party funding the plan.

  • Methods of selecting a dentist.

  • Compensation of the dentist's services to you.

  • The calculations of benefits and payments.

Understanding these differences will enable you to make an informed decision when selecting a dental plan that is best for you or your family.

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