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Why Offer a Dental Benefit Plan?

Did you know that dental caries is the most common chronic disease in children and is 5 times more common than asthma? Severe gum disease affects 19 percent of adults aged 25-44. In addition, there are approximately 35,000 oral cancers diagnosed annually

Economic and social consequences of oral pain, dental decay and tooth loss include poor school and work performance, poor nutrition and social stigma. In children, oral pain can adversely affect speech and language. Regardless of age, dental restoration can be very costly.

Approximately 25 percent of adults avoid smiling and/or feel embarrassed due to the condition of their mouth and teeth; while, about 20 percent of adults experience anxiety due to the condition of their mouth and teeth. Additionally, poor oral health can result in adults having poor self-esteem which can make it difficult to interview for a job. According to the Health Policy Institute (HPI), Oral Health and Well-Being in the United States brief, 29 percent of low income adults, and 28 percent of young adults ages 18 through 34 reported that the appearance of their mouth and teeth affects their ability to interview for a job.

A recent survey from the National Association of Dental Plans reported that 80 percent of employers were aware that good oral health reduces the impact of medical conditions, while 4 percent did not agree and 16 percent were ambivalent. Consumers, however were asked what medical conditions were linked to poor dental health – 64 percent reported coronary artery disease, 57 percent reported oral cancer and 27 percent reported diabetes. This indicates there is a knowledge gap in your employees’ understanding and attitude towards oral health.

In addition to promoting oral health, a quality dental benefits plan can aid in the recruitment and retention of employees. Dental benefits are highly sought after and valued by employees. In fact, according to the National Association of Dental Plans, employees rank dental plans as the third most important employee benefit.  

Is your Current Dental Benefit Plan Working?

We all agree that healthcare value is outcomes over cost. Getting value from any benefit really depends on how well that benefit is applied towards health and well-being. To achieve health and well-being, health care must be utilized. However, while 77 percent of adults plan to visit the dentist within the next year, only 37 percent of adults actually visited the dentist within the last year. The HPI brief, An Analysis of Dental Spending among Adults with Private Dental Benefits reveals that one in three adults with private dental benefits do not utilize any dental services.

What is preventing adults from visiting the dentist? Even among people with a dental benefit, cost is the number one reason for not visiting the dentist in the past 12 months. (1)  And while it is true that just under 3 percent of enrollees reached their annual maximum in 2014, how many enrollees did not proceed with necessary treatment recommended by their dentist because they would have exceeded their plan’s annual maximum?  

Remember, when calculating the total cost of care, you must be sure to include the cost of premiums in addition to deductibles and co-insurance as many times this exceeds the value of the dental care received based on actual dentist charges. It is also important to note that for many people, coming up with a 50 percent co-insurance payment for major work is extremely difficult.

Want to speak with someone about selecting a dental benefit plan? You can call the ADA’s Center for Dental Benefits, Coding and Quality at 312.440.2500 or email

1 American Dental Association Health Policy Institute. Oral Health and Well-Being in the United States. May 2016. Available from: Accessed October 11, 2016.

Things to Consider Before Selecting or Changing your Dental Plan

Before selecting or changing a dental plan, there are many important factors to take into consideration. Most plans are designed to pay only a portion of your employee’s dental expenses. However, dental plans may exclude or discourage certain treatments, such as dental sealants, which can prevent tooth decay and save money later on. Be careful to understand just exactly what a plan will and will not cover and be sure to know its limitations before a decision is made. For information on individual plans, please visit MouthHealthy.

Plans are however, slowly evolving to better meet the needs of employees. Some plans will allow employees the option to rollover unused benefits from one plan year to the next. Still other plans may not count some preventive and diagnostic services towards the plans’ annual maximum benefit (meaning more benefits are available for other services). Also, some plans now provide additional benefits to employees with certain medical conditions, for example, a patient with diabetes may be allowed extra periodontal cleanings. It is recommended you ask your plan about coverage for these additional benefits.

Before selecting or changing a dental plan consider asking the following questions:

  • Will employees have the freedom to choose any dentist they want, or do they have to go to a dentist within a specific provider network?
  • Does the plan cover all of the services that you typically need? What are the limitations to the coverage?
  • Does the plan cover orthodontic treatment? Is there a lifetime maximum?
  • What limitations does the plan place on pre-existing conditions like missing teeth?
  • Will the plan allow for rollover of unused benefits when a patient fails to reach the plan’s annual maximum benefit?
  • Will the plan count preventive and diagnostic services towards the plan’s annual maximum benefit?
  • Will the plan provide additional benefits to employees with certain medical conditions (e.g., diabetes)?
  • Will the plan allow for care by specialists? Is coverage limited to contracted specialists, or may patients see the specialist of their choice?
  • How does the plan provide for emergency treatment? Is there coverage when a patient must see a non-contracted dentist after hours or while traveling?
  • What percentage of the premium dollars paid by employers or beneficiaries goes to actual treatment? What percentage goes to administrative expenses?
  • What percentage of enrollees actually accessed dental services?
  • What percentage of children received a dental evaluation and preventive services?
  • What percentage of adults with gum disease received follow-up care from a dentist?
  • What is your plan doing to promote utilization of dental services for your employees?

Notice that we have used the term dental benefit plan and not dental insurance.  Insurance plans are designed to make an employee whole in the event of a loss. Insurance, by definition, entails a risk of loss to the insurance company.  Typical dental benefit plans are not designed to cover all dental procedures, and dental benefits coverage is not based on what your employees need or what the dentist recommends.

Based on what you have read so far regarding the importance of oral health, the link between oral and systemic health and the true costs of a dental plan, do you think your current dental plan is delivering the value you and your employees expect and need? Do you feel your plan is accountable for improving the oral health of your employees? Do you even know if your employees are achieving optimum oral health?

Coverage for Retirees

The ADA recognizes the importance of extending dental benefits to retirees and encourages plan purchasers to consider the continuation of dental coverage for retiring employees if it was offered in the past, or as an option for retirees to purchase at their own expense if it is not part of an employee retirement package.

Direct Reimbursement 

With Direct Reimbursement (DR®), it's easy to create a dental plan to meet your company's specific needs.
DR is a self-funded group dental plan in which the employee is reimbursed based on a percentage of dollars spent for dental care provided, and which allows employees to seek treatment from the dentist of their choice.

Find out why thousands of companies are already enjoying the simple advantages of Direct Reimbursement.

The American Dental Association strongly supports DR, the dental profession's preferred method for financing dental treatment. The two primary reasons for this support are freedom of choice and fee-for-­service dentistry.

Direct Reimbursement (DR®) PowerPoint Presentation

Glossary - Understanding your Dental Benefits

For your quick reference, the terms relating to dental benefit plans that are used herein are defined below.

Contract Dentist - A dentist who agrees to provide specified services at specific levels of reimbursement under the terms and conditions stipulated by the contract.

Contract Term - The period of time, usually 12 months, for which a contract is written.

Deductible - The amount of a dental expense for which the beneficiary is responsible before a third party will assume any liability for payment of benefits. The deductible may be an annual or one-time charge, and may vary in amount from program to program.

Eligibility Date - The date an individual and/or dependents become eligible for benefits under a dental benefits contract. This date is often referred to as the "effective date."

Exclusions - Dental services not covered under a dental benefit program.

Fee-for-Service - A method of reimbursement by which the dentist establishes and expects to receive his or her full fee for the specific service(s) performed.

Fee Schedule - A list of the charges for specific dental procedures established or agreed to by a dentist.

Flexible Spending Account (FSA) - An employee reimbursement account primarily funded with employee-designated salary reductions. Funds may be reimbursed to the employee for health care (medical and/or dental) and dependent care and are considered a nontaxable benefit.

Freedom of Choice - The concept that a patient has the right to choose any licensed dentist to deliver his or her oral health care without any type of coercion.

Managed Care - A type of dental plan that is a contractual arrangement in which payment or reimbursement and/or utilization is controlled by a third party. This concept represents a cost containment system that directs the utilization of health care by: a) restricting the type, level and frequency of treatment; b) limiting the access to care; c) controlling the level of reimbursement for services; and d) controlling referrals to other dentists.

Pre-authorization - A statement by a third-party payer indicating that proposed treatment is covered under the terms of the benefit contract. Some plans require a dentist to submit a treatment plan to a third-party payer for approval before treatment is begun.

Pre-certification - Confirmation by a third-party payer of a patient's eligibility for coverage under a dental benefit program.

Pre-determination - A process used to determine the benefits available for dental services that are planned by the dentist: an estimate of the amounts payable by the plan if services are rendered when the patient is eligible. Under some programs, predetermination by the third party is required when covered charges are expected to exceed a certain amount.

Premium - The regular (typically monthly) fee charged by third-party insurers and used to fund the dental plan.

Reimbursement - The payment made by a third party to a beneficiary, or to a dentist on behalf of the beneficiary, toward repayment of expenses incurred for dental services covered by the contractual arrangement.

Self-funded plan - A benefit plan in which a plan sponsor (usually the employer) finances the entire employee benefits, in place of purchasing such coverage from a commercial carrier.

Third-Party Administrator (TPA) - An individual or company that processes and pays claims for self­ funded dental plans. The TPA undertakes no financial risk for claims incurred. Some commercial insurance carriers and plans also have TPA operations to accommodate self-funded employers seeking administrative services only (ASO).

Third-Party Payer - An organization, usually an insurance company, other than the patient or health care provider (i.e., dentist) responsible for paying the provider designated expenses incurred on behalf of the insured (i.e., the patient).

Utilization - The extent to which the members of a covered group use a program over a stated period of time; specifically measured as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals.