How Your Dental Plan Works
What do you get when you buy a dental plan? Just like health insurance, you get access to a network of dentists and coverage for care and treatment you receive.
Provider network: trusted dentists
Every dental plan has a network, which is a group of dentists that works closely with an insurer to serve its members. With most dental plans, you can get care from either an in-network or out-of-network dentist. In-network dentists are known as participating providers. They have a contract with the insurance plan to provide services at a set fee. You can see a nonparticipating (out-of-network) provider, but you may pay more than if you were to see a participating provider. Participating providers also file claims on your behalf. Learn more about provider networks.
Types of dental plans
Preferred Provider Organization (PPO) and prepaid or dental health maintenance organization (DHMO) plans are two of the most common types of dental—and health—insurance. DHMO plans usually have lower premiums than PPO plans but offer a smaller provider network and often lower reimbursement for services.
BlueDental Copayment, Choice and Choice Plus are PPO plans. BlueDental Care is a prepaid plan that works like an DHMO.
PPO/HMO Network Comparison Chart
| PPO | DHMO/Prepaid | |
| Choosing a Dentist | See any dentist and get discounts on services when you visit participating providers. | Benefits apply only when you see participating providers. You must also select a primary dentist. |
| Specialist coverage | No referral needed to see a specialist. | Some plans offer specialist coverage; check your policy for details. For plans that don't include coverage, you may receive a 25% reduction from Participating Specialists' usual fee for covered dental care services performed. |
| How you pay | A percentage of the cost is paid when you meet your annual deductible. Copayments may apply for some plans. | You pay a set copayment at each visit. |
| Annual maximum | Yes, but some plans allow you to rollover unused benefits. | No. |
| Advantages | Flexibility—see the dentist of your choice, in- or out-of-network. Larger networks of dentists. No referral needed to see specialists. | Lower monthly cost. No annual maximum. |
| Limitations/considerations | Higher monthly cost. | Benefits don’t apply if you see a nonparticipating provider (a dentist who’s not in the network). |
If you have a dentist, check our provider directory to see if your dentist is in our PPO or DHMO network.
BlueDental PPO vs. Prepaid
If you’re a BlueDental PPO member, you have access to a large dental network in Florida and nationwide. If you choose a dentist in our network, you can realize greater savings, including low or no out-of-pocket costs for preventive services. The networks for BlueDental Copayment, Choice and Choice Plus plans are each a little different, so be sure you select your plan when using the “find a dentist” tool.
Our BlueDental Care prepaid plan has a smaller network and provides no out-of-network benefits. If you are considering selecting a BlueDental Care plan, it’s a good idea to first check whether your dentist or a dentist near you is in the Care network. You will also need to choose a dentist from the Care network when you enroll in your plan.
Dental services
The purpose of insurance is to provide you with a layer of financial protection against a possible risk. Just as auto insurance helps cover the cost of fixing or replacing a car damaged in an accident, dental insurance provides coverage for services such as fillings if you get a cavity or crowns if you damage a tooth. Dental services generally fall into three categories:
- Preventive: Most dental plans cover preventive care at 100%. This includes exams, cleanings, and X-rays. With some plans, preventive services for children, such as sealants, are covered at no additional cost.
- Basic services: Treatment for gum disease, tooth extractions, fillings, and root canals is considered basic. Most dental plans will pay most of the cost of these services, while you’ll be responsible for a portion of the cost.
- Major procedures: Crowns, bridges, inlays, and dentures involve higher out-of-pocket costs than basic procedures.
Some plans may include coverage for orthodontia, such as braces or dental implants. Also, dental services may be categorized differently based on your plan. Make sure to check your plan’s policy before you receive services.
What you pay for dental insurance
Like most types of insurance, you must make regular payments to get and keep your coverage. This is called a premium. There are cost-sharing payments called “out-of-pocket expenses” that you may need to pay for certain treatments. Unlike premiums, out-of-pocket expenses are tied to services you receive and they help keep premiums more affordable for everyone.
- Premiums: The amount you pay monthly for your dental plan.
- Cost sharing or out-of-pocket expenses:
- Deductible: A fixed amount you may need to pay for covered services before your insurance plan begins paying.
- Copayment: A fixed amount you pay at each visit to the dentist. Copayments don’t apply to your deductible.
- Coinsurance: A percentage of the cost for a service.
All plans require premium payments and many have a deductible. All plans have either a copayment or coinsurance for some services. Different plans offer different payment give you more options to find a plan that works best for your financial situation.
Out-of-pocket costs are often capped for pediatric dental coverage. This is called an out-of-pocket maximum and is the total amount you’ll pay for dental care during a calendar year. Coverage for adults usually doesn’t have an out-of-pocket maximum.
Other important factors
Annual maximum benefits
PPO dental plans typically have a yearly limit on what the plan will pay for services. According to the National Association of Dental Plans (NADP), less than 3% of people with PPO dental plan participants reached or exceeded their plan’s annual maximum. If you do, however, you may be responsible for paying costs over the maximum.
Waiting periods
Some dental plans require you to wait for a period of time before you receive certain services. Review your policy to see if any waiting periods apply.
The benefits of dental coverage through Florida Blue
At Florida Blue, we offer a choice of affordable, high quality plans that provide you with benefits that help prevent issues and improve your dental health. Check out our plan comparison page, or talk to an agent or one of our helpful representatives at a Florida Blue Center near you.