Pros and Cons of Purchasing Individual Dental Insurance

When is it cost effective to buy Individual dental insurance?

People ask me all the time what dental insurance I recommend. My answer is, it depends. There are pros and cons of purchasing individual dental insurance.

To get a good value out of your individual dental insurance, consider these 2 things:

  1. Does my current dentist participate in any dental insurance networks?
  2. If they don’t, will they accept any PPO dental insurance?

Most dentists don’t participate in dental insurance networks because they have to accept reduced fees for their services. When a dentist participates in a dental network, they have to agree to not charge the member more than the reimbursement fee schedule of the dental insurance company. That is an advantage for you as a member because you can get more coverage for your dental work for less.


Dental HMO

In some cases, such as with a dental HMO network, the fee schedule is greatly reduced from what the dentist would normally charge. Reasons why a dental office would participate could be 1) The dentist or the dental office is new and trying to build a client base 2) The dental office wants to build volume for their practice and offering reduced fees will bring in more clients 3) The dental office is well established and they have found that over time serving everyone, regardless of their profit is good business.

If your dentist participates in a dental HMO provider network, you can get the most out of your dental insurance at the lowest cost. If you are willing to change dentists or you need to pick a new dentist anyway, a dental HMO plan would have the most value from both a benefits and a cost perspective.

Here are the pros and cons of Dental HMO:

Pros Cons

Costs less Not very many dental offices to choose from

Better coverage Dentist office may try to upsell other procedures to make up for less profit

Dental PPO

If your dentist only takes PPO dental plans, go to their website or call them to find out if they participate in any dental networks and ask if they are DHMO or dental PPO (DPPO) networks and which ones. Let us know the names of the dental networks and we’ll include those in your quote.

If your dentist participates in a dental PPO network, you will get the most value out of the plan because the dentist can only charge you the maximum allowed amount and your out of pocket maximum for the year will go a lot farther.

Here are the pros and cons of Dental PPO:

Pros Cons

Go to any dentist Pay more out of pocket for an out of network dentist

Preventive care usually covered at 100% Watch out for balance billing I the dentist is not in

Higher max out of pocket covered the dental PPO network

What if your dentist doesn’t participate in any dental networks but they will bill any dental PPO plan? Then you will want to pick a dental plan that offers the most reimbursement for your dental claims. Some dental companies use their own dental claims data to determine the maximum they will pay (using their participating dentists fees which are reduced) and others will base their reimbursement on Usual and Customary.  Usual and Customary is the best reimbursement schedule for you because it is usually based on an industry average of what dentist charge in your area.  If they pay at the 80th or 90th percentile, then it means that your claims will be paid at 80% or 90% of what most dentists charge.

Now that you have taken the time to figure out if your dentist participates in any DHMO or DPPO networks, here are some guiding questions?

What are the most important things to look for in the dental plan you are considering?

  1. Is my dentist in the network?
  2. With a dental PPO plan, what is the out of network reimbursement schedule based on?
  3. What is the maximum the plan will pay out for the year?
  4. Does the plan have a deductible and what is subject to the deductible?
  5. Is preventive care covered at 100%?
  6. Is there a waiting period for any services?
  7. What are the exclusions of the plan?
  8. Does the plan cover major services such as crowns and root canals?

Tip: If you need to have any dental work done that will cost more than $100, ask your dentist’s office for a predetermination of benefits. A predetermination of benefits will be an itemized cost your dentist office will get from your dental insurance company to find out what your final cost will be after the insurance pays their part.

For more information on dental insurance or to get a quote for dental insurance, please contact Benefits by Design Insurance Services at 760-696-3573 or