Individual Dental Insurance
Proper dental care had long been considered an affordable expense for many years. That is why most employer sponsored group health insurance plans never included it. As the cost of dental care increased over the years, dental insurance gained in popularity and more employers during the 1970’s began adding dental insurance coverage to their employee benefit programs. Despite the rapid adoption of group dental insurance by employers today, it is estimated that only 62% of employers actually offer dental coverage.
If you do not have dental insurance, you may want to consider an individual dental insurance plan in order to help maintain proper health wellness, and financial well being.
Studies show those without full coverage dental insurance are less likely to see a dentist than those with dental insurance. The uninsured tend to visit a dentist only when they have a problem and are less likely to see a dentist regularly for preventive care.
According to the American Dental Hygienists’ Association, oral health is a critical component of total health. Recent research has linked periodontal disease to heart and lung disease, diabetes, low-birth weight babies, and a number of other systemic diseases. Dental caries (decay) is the most common chronic disease nationally affecting 53% of 6-8 years olds and 84% of 17 year olds. Fortunately, caries is preventable through the use of fluoride and dental sealants and is less than half the cost of one silver filing. Serious oral health problems also occur among adults too. Each year about 30,000 Americans are diagnosed with oral and pharyngeal (throat) cancers, and more than 8,000 people die of these diseases. In addition, almost 30% of elderly adults no longer have their natural teeth due to tooth decay and gum disease.
Cost of restorative treatment is more expensive than preventive services
|Average Cost of Common Dental Procedures||Min. Cost||Max. Cost|
|Exam & Cleaning||$86||$110|
|Complete X-Ray Series||$123||$171|
The Coalition for Oral Health, representing a wide spectrum of oral health associations, reported that $1 spent for prevention saves from $8 to $50 in restorative care.
Good oral hygiene can prevent disease. The early detection and treatment of oral disease is critical to saving lives. During oral health examinations, dental hygienists can detect signs of many diseases and conditions like HIV, oral cancer, eating disorders, substance abuse, osteoporosis and diabetes. In addition, dental hygienists can work with patients to develop oral health care treatment plans that manage oral infection so it does not exacerbate serious diseases.
Full Coverage Dental Insurance- Covered Services
Most individual dental insurance plans help pay for the cost of the following services:
1. Preventive: cleaning, exams, sealants and fluoride treatment
2. Diagnostic: bitewing x-rays and full mouth x-rays
3. Basic: fillings, simple extractions and repairs
- Oral Surgery
- Periodontics – treatment of diseases affecting the gums and supporting structures
- Prosthodontics – replacement of missing teeth and related mouth or jaw structures by bridges, crowns, dentures or other artificial devices
- Endodontics – treatment of diseases of the dental pulp, tooth root, and surrounding tissues, including root canals
5. Orthodontia: correcting irregularities of the teeth by the use of braces or other devices
Types of Dental Insurance
There are several types of dental insurance plans, including:
- Dental Preferred Provider Plans
- Dental Maintenance (DMO) Plans
- Scheduled Reimbursement Dental Plans
- Discount Dental Plans
Indemnity Dental Insurance
These are “traditional” dental insurance plans where the health insurer pays a percentage of your dental expenses. Since there are no dental network providers, you can obtain dental care from any dentist.
After you satisfy the deductible, the dental insurance plan generally covers 100% of preventive services (cleaning), 80% of restoration services (root canal) and 50% of major treatment, such as orthodontics (braces), up to an annual maximum (usually between $1,000 and $2,000).
Indemnity dental insurance will pay based on the Reasonable and Customary (R&C) expense. That means if your dental provider charges more than the R&C expense, as determined by the dental insurance company, you will be responsible to pay your dentist the difference. Additionally, individual dental insurance may contain waiting period(s) for certain services.
Benefit payments for covered dental services made by the dental insurance plan can be paid to you or directly to your dentist, if you assign them.
Dental Preferred Provider Plans (PPO)
Although, generally less expensive than indemnity dental insurance, PPO (Preferred Provider Organization) dental plans work very much the same way. These plans offer the option to obtain dental care from a network provider. Since the dental insurance company has negotiated discounts with participating providers you pay less for dental services. While individuals can also seek treatment from dentists outside of the dental PPO, they will generally have higher deductibles and/or co-payments.
Just like indemnity dental insurance plans, payments made by the dental insurance plan can be paid to you or directly to your dentist, if you assign them. R&C, however, does not apply because the dental provider cannot bill more than the negotiated rate. That means, your dentist charge you for the difference between the negotiated rate and his/ her retail charge for the dental services rendered.
DMO Dental Insurance
These dental plans, also called DMO’s, operate the same as health maintenance organizations. As a result, they maintain a much smaller network of dental providers because DMO’s pays a set fee each month to the participating dentist you select. This payment is usually referred to as the “capitated” rate and represent pre-payment by the dental insurance company directly to your dentist for providing dental care, regardless of how much or how often you need dental services.
DMO Plans reward participating dentists who keep patients in good health and keep plan costs low. The insurance premium for a DMO dental plan is generally the lowest of any type of dental insurance plan. Your out-of-pocket expense for dental services is also less too. However, the trade off is less flexibility because there are much fewer dental providers to choose from than traditional PPO dental plans and your care must be rendered or managed by the dentist you select.
Dental Discount Plans
Discount dental plans are not insurance. They simply provide discounts for a wide range of dental services when care is obtained from a network dentist. The entire family can use the discount plan. Since there is no waiting period(s) you can receive treatment immediately. These health discount plans represent a great value and excellent alternative if you do not have or cannot afford full coverage dental insurance.
At healthinsuranceadvisory.org, we offer a FREE health discount plan. This program offers significant discounts on prescription drugs, dental expenses and vision services at major chains and local providers across the country. Everyone qualifies. No enrollment, membership or monthly fees. Use it immediately for the entire family. There are no usage restrictions and you are not required to provide personal information to get one!
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Scheduled Dental Reimbursement Plans
A Scheduled Dental Plan reimburses you for a specific dollar amount based on a pre-determined fee schedule that appears in the dental insurance policy. This fee schedule lists a wide range of dental services and shows exactly how much the dental insurance plan will pay for each service. Most scheduled dental plans have a deductible and calendar year maximum. Some have waiting periods for certain procedures.
You are responsible for paying your dentist the difference between what the dental insurance policy pays and the amount of your dentist’s actual charges.
Can Individual Dental Insurance Benefit You?
Individuals purchase full coverage dental insurance for many reasons, such as:
1. Financial protection – without some form of dental insurance to help cover the expense of dental care, the cost of paying for expensive dental procedures, such as restoration, surgery, endodontic and periodontal services, is simply not affordable.
2. Maintain a healthy mouth and overall wellness – studies show that regular dental check-ups and cleanings help promote overall health. That is why most dental insurance pays 100% for routine exams and cleanings every six months.
3. Prevention for children – from fluoride treatment to sealants and braces, children can benefit significantly from regular professional dental care. Dental insurance can help make the cost of preventive care more affordable, even orthodontia.
Individual Dental Insurance and Medical Insurance
- Individual Medical Insurance Plans
Low cost medical insurance coverage is what all Americans want. Roughly 9% of individuals, families and the self-employed today buy medical insurance in the individual medical insurance marketplace, while 59% of Americans obtain their major medical insurance through an employer sponsored health plan.
If you do not have access to employer sponsored medical insurance, then we can help you understand your options so you can secure an affordable medical insurance plan. We believe an educated consumer makes better decisions. That is why our goal at healthinsuranceadvisory.org is to provide better tools and information to empower consumers.
Factors that influence the cost of major medical insurance
In most states, the premium you pay for an individual major medical insurance plan is based on the applicants:
- place of residence,
- health status, and
- type of medical insurance plan selected.
Currently, individual major medical insurance is medically underwritten (except for children less than 19 years of age). That means each applicant is required to provide their health history when they apply for a medical insurance plan. The health insurance company will use this information to assess (underwrite) each applicant’s insurability. Your build (height/weight), tobacco status, past and present medical conditions, including treatment, prescription drug usage and even high risk hobbies (motorcycling, hand gliding, scuba diving, etc.) can affect your insurability and the medical insurance premium you pay.
Note: The new healthcare law, called the Patient Protection and Affordable Care Act, requires health insurance companies to cover children less than 19 years of age regardless of their health status, effective September 2010. This new mandate is applicable to group or employer sponsored health insurance and individual major medical insurance plans.
Effective January 2014, health insurance companies must accepts all applicants, regardless of their health status, and must cover pre existing medical conditions.
What happens if I do not disclose all of my health status?
Many people wonder about the consequences of not truthfully and completely answering the medical questions on the major medical insurance application. Withholding information from a medical insurance company can have very serious consequences. It is very common for health insurance companies to issue a medical insurance policy based on the applicant’s responses to the health questions on the application. If the health insurance company believes there is no reason to ask for medical records or dig deeper into the applicant’s health status to process the application, they will not.
The health insurance company can request medical records, however, after claims are submitted. This process is called medical review. The purpose is to validate if the claims were related to a health condition that existed prior to the medical insurance policy going into effect. Not all claims are subject to medical review. While the new healthcare law limits health insurance companies ability to rescind (retroactively cancel) or reform (modify) coverage (there must be fraud or intentional misrepresentation on behalf of the applicant), an individual could be left with no medical insurance and required to pay their legal expenses and medical bills. Bottom line: always answers health questions on any insurance application honestly and completely. Learn more about recission of major medical insurance.
What if I have pre existing medical conditions?
With the passage of the new healthcare law, new consumer protection rules went into effect in 2010. They are:
- Children less than age 19 must be accepted for major medical insurance (“guarantee issue”) and health insurance companies must cover their pre existing conditions. Learn more about guaranteed dependent medical insurance.
- Young adults less than age 26, can remain on their parent’s major medical insurance plan, regardless of their place of residence, parental financial dependence, and marital, employment or student status. Learn more about securing dependent coverage up to age 26.
While this is positive news, individuals age 26 and older can still be medically underwritten until January 2014. As a result, the medical insurance company can decline to issue a medical insurance policy or place an Exclusionary Endorsement on any pre existing condition(s). This endorsement effectively excludes the specified health condition(s) from being covered for at least one year. If you find yourself in this situation, then request the health insurance company remove the endorsement after the first 12 months.
If you have an existing health condition and unsure how it will impact your ability to obtain an individual major medical insurance plan, then use our exclusive Insurability Profile Tool™. It is fast, confidential and free. You will receive immediate feedback regarding how a medical insurance company will likely respond to your health status. Learn more about my insurability.
- Beginning in 2014, the new healthcare law requires health insurance companies to accept all applicants who apply for an individual major medical insurance plan, regardless of their age or health status. Additionally, coverage cannot be restricted in anyway. Pre existing conditions must be covered.
Types of major medical insurance plans
Many different types of major medical plans are offered by health plans and medical insurance companies today, such as:
- HMO (Health Maintenance Organization)
- PPO (Preferred Provider Organization)
- POS (Point of Service)
The primary differences between these plans are the:
- type of healthcare provider network offered (or not in the case of Indemnity medical insurance plans),
- the rules surrounding use of network providers (flexibility to use any healthcare provider or requirement to obtain a referral to see a specialist), and
- the plan’s emphasis on preventive care.
In the past, HMO’s were known for their emphasis on preventive care and treating potentially serious health conditions before they manifested into big dollar claims. PPO, POS and Indemnity plans, on the other hand, historically did not cover proactive treatment (routine check ups and screenings). Over the years though, most states enacted wellness benefit mandates. As a result, these plans evolved to cover routine physicals, mammography, pap smears, cancer screenings, etc.
Since the new healthcare law was passed, all major medical insurance plans are now required to cover the cost of preventive care, as recommended by the U.S. Preventive Services Task Force at 100%. Learn more about the preventive care services mandated by the new healthcare law.
Consumers now have greater piece of mind knowing that all medical insurance plans are required to cover the same preventive care benefits. This is one reason why high deductible PPO Plans are more attractive today. Individuals and families can benefit from paying a lower premium and having preventive care services covered at no charge. Learn more about high deductible medical insurance.
For even greater financial savings, many individuals open a Health Savings Account with a qualified high deductible plan. The added tax savings from paying for out of pocket qualified healthcare expenses with pre tax money can significantly improve one’s financial situation. Learn more about the advantages of Health Savings Accounts and how they work.
Learn more about the different types of major medical insurance.
What are my options for medical insurance?
Depending on your situation, several options may be available to you for major medical insurance. For example, if you were recently covered under an employer sponsored health insurance plan, then you may have certain rights to continue that coverage or purchase an individual major medical insurance plan regardless of your health status. Identifying these alternatives and helping you understand them is our mission at healthinsuranceadvisory.org.
COBRA continuation coverage
Passed by Congress in 1985, the Consolidated Omnibus Budget Reconciliation Act requires health insurance continuation coverage be offered to employees, their spouses, their former spouses and their dependent children when group health coverage would otherwise be lost due to specific events. Continuation coverage must be made available for 18, 29, or 36 months. Although generally expensive, COBRA can be an excellent alternative for individuals who cannot obtain an individual or self-employed medical insurance policy due to pre existing health conditions. Learn about COBRA eligibility requirements and other important details.
For individuals currently covered under an employer (group) health insurance plan that are leaving the employer, it might be possible to convert the job-based health insurance plan to an individual medical insurance plan. This is called “conversion” coverage. It is not the same as COBRA continuation coverage because benefits are usually reduced or limited. Contact your employer for information.
The Health Insurance Portability and Accountability Act (HIPAA) guarantees the right to purchase private major medical insurance to “HIPPA eligible individuals,” regardless of their health status. HIPAA also prohibits health insurers from excluding pre existing conditions under the medical insurance plan.
A “HIPAA Eligible Individual” is someone who has/ is:
- Had continuous (no break in coverage for 63 days or longer) credible medical insurance coverage for at least 18 months with the most recent coverage being under a group health plan,
- Lost group coverage due to circumstances other than fraud or non-payment of premium (whether you quit your job, were fired or laid off does not matter),
- Elected and exhausted COBRA continuation coverage, if eligible (employers less than 20 employees are not subject to COBRA),
- Not be eligible for coverage under another group health plan, Medicare or Medicaid, and
- Not currently covered under a medical insurance plan
Depending on the state, “HIPAA eligible individuals” may purchase individual medical insurance directly from health insurers or their state’s High Risk Pool. These plans are required to offer individual medical insurance regardless of a person’s health status. Learn more about HIPAA.
Medicaid offers healthcare coverage to certain people with limited income that meet their state’s Medicaid eligibility requirements. Generally, children and parents, pregnant women, people with disabilities and seniors are included. Medicaid programs are run by states with a mix of state and federal funding. There are certain core rules all states must follow, but some Medicaid rules vary by state.
Since most states are currently facing severe budget deficits, Medicaid eligibility rules and benefits may have recently changed. Visit our Government Plans section for links to your state’s health insurance programs.
State Children’s Health Insurance Plan
If you are seeking health insurance for your children, President Obama signed the Children’s Health Insurance Bill on February 4, 2009. It enables millions of children to receive medical insurance. The eligibility rules for the Children’s Health Insurance Plan are unique because every state has its own program and rules. Generally, uninsured children 18 years old and younger whose families earn up to $44,500 a year (for a family of four) are eligible for free or low-cost medical insurance that pays for doctor visits, dental care, prescription medicines and hospitalization. Visit our Government Plans section for the link to your state’s Childrens Health Insurance Plan.
Pre Existing Condition Insurance and High Risk Pool Plans (PCIP)
The PCIP is a new program under the new healthcare law. It is administered by either states or the Federal government. The PCIP may help if you are unable to qualify for individual major medical insurance and meet the following qualifications:
- Uninsured for at least six months
- Have a pre existing medical condition(s), and
- Have been denied coverage (or offered insurance without coverage of the pre existing condition) by a private health insurance company.
The PCIP covers major medical and prescription drug expenses. You are responsible for paying premium, deductible, copayments, and coinsurance amounts. The PCIP will not cost you more just because of your health condition. Unlike Medicaid, eligibility for the PCIP is not based on income. Visit your state’s specific medical insurance page within healthinsuranceadvisory.org for more information regarding the PCIP.
Guaranteed Health Insurance
If you are unable to qualify for major medical insurance, then Guaranteed Health Insurance, also called pre existing condition medical insurance may be an alternative. Since most guaranteed health insurance plans are not medically underwritten acceptance is guaranteed. While considered supplemental medical insurance, not major medical insurance, these plans typically pay a fixed dollar amount for covered healthcare expenses, such as physician office visits, diagnostic services, lab, x-ray, surgery, inpatient confinement and wellness.
The primary reasons individuals purchase guaranteed health insurance is because they:
- Cannot qualify or afford individual major medical insurance
- Want an ID card to gain access to the healthcare system in the event that unexpected medical care is needed
- Want some financial protection against expensive medical bills
Learn more about pre existing condition medical insurance.
Short Term Medical Insurance
If you are healthy and need major medical insurance for less than 12 months, then short term medical insurance is something to consider. These affordable temporary health insurance planshelp individuals fill a short-term gap in coverage. Short-term medical insurance also helps individuals maintain continuous health insurance coverage in order to maintain HIPAA eligibility status. This is important because HIPAA eligible individuals are guaranteed the right to purchase individual major medical insurance, regardless of their health status. Learn more about short-term medical insurance.
Let us help you find and secure an affordable individual medical insurance plan today! Our online medical insurance quotes make it fast and easy to shop and compare medical insurance plans from many of the top health insurers in your area. You can even apply online too!