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Dental plans are probably the second most popular benefit behind health insurance.  It may also be the benefit causing the most confusion for many employees.  In some ways, dental benefits work like health insurance benefits, but there are differences.  In order for any benefit to work smoothly, the employee needs to be diligent and understand his/her benefits to insure he/she receives the expected quality of care at the expected out-of-pocket cost. 

Participating Networks
Like health insurance, most dental plans have both in-network and out-of-network benefits.  But unlike health insurance, where the majority of providers (doctors) and hospitals are in-network, the percentage of participating dentists (in-network) is much lower with dental insurance companies relative to the total population of dentists.  The out-of-pocket expenses will probably be what one expects if a participating dentist is seen.  But if you see a non-participating dentist, you will probably be “balance-billed” and pay more than what you expected.  Employees should be encouraged to choose a reputable participating provider with any Health and Welfare plan.  There are available dental plans that will minimizing  the balance-billing problem with non-participating dentists.

Annual Maximum Benefit

Another difference between dental plans and health insurance is the cap on annual benefits.  Most health insurance plans either do not have an annual cap or have a very high annual benefits cap.  If you have a catastrophic health condition, the health insurance plan will cover all medical service expenses unless a service is not covered.  Most dental plans have a relatively low cap on the claim amount it will pay each year – most ranging from $1,000 to $2,000.  As an illustration, a root canal (estimated at $1,200) and a crown (estimated at $1,000) in one calendar year would meet the $1,000 annual benefit paid out by the dental plan.  If you have a $1,000 plan, the plan will pay $1,000 in claims, but the employee will be responsible for 100% of the expenses exceeding the annual cap without any cost sharing with the dental insurance company.  The annual maximum will reset each year (usually based on the calendar year regardless of when your anniversary date is).

Assessment Questions

  • Does your dental plan have an open enrollment period?  Most dental plans do not meaning employees who do not enroll when eligible will not be able to enroll late (even on the anniversary date of the plan, without (1) a qualifying event, or (2) an impairment rider requiring an 18-24 month waiting period for Basic and Major Services.


  • Did you know most plans offering ortho coverage do not cover adults?  Most carriers will cover adults if specifically asked for by the broker at a slightly higher premium.


  • Are your employees instructed to ask for a pre-treatment plan before having a procedure done?  Not all carriers require a pre-treatment plan from participating providers and a non-participating provider will absolutely not be required to present one.  If a pre-treatment plan is not requested, you are gambling that the carrier will cover (pay for) the entire procedure.


  • Did you know up to 40-60% of all dentists in any area may not participate with your dental plan?  Do you understand balance billing?  Are you aware of UCR (R&C) dental plans and how these may help your employees?


  • Did you know for a small additional premium, endodontics, periodontics, and oral surgery may be classified as a Basic Service rather than the default, Major Service?  The change may result in a difference of paying 20% of the total charge rather 50% of the total charge.  Or 20% of a $1,200 root canal rather than 50% of a $1,200 root canal.


  • Do you and your broker follow the HIPAA and HITECH regulations regarding electronic transmission of Protected Health Information?  Are you emailing Social Security numbers and sensitive health information?


  • Does your broker regularly educate you and your employees on the details of your plans?


  • Does your broker resolve your claims issues?

For more information, please contact Bridgeport Benefit Advisors.

The material on this page is intended as general descriptions of the concepts presented.  It is for educational purposes only and it not intended to provide specific financial or tax advice.  These descriptions cannot take into account your specific conditions and situation including the data required for underwriting purposes, financial circumstances, risk tolerance, and other factors.