What You Need to Know About Dental Care in the FEHB Program
Plans' dental benefits differ widely in details, and many of the brochures use technical terminology such as "gingival" (gum, in English), "alveolar" (the part of the jawbone that holds teeth in place), and "amalgam restorations" (filling cavities). Moreover, many plans use schedules of allowances, so you don't know if the full charge will be paid (usually not). Since most of the plans limit coverage to the items listed in the schedule of allowances, the problem you have may not be covered at all. Worst of all, no plans offer a catastrophic dental benefit that would cover you if, for example, you developed a chronic infection of the jaw and required dental procedures costing thousands of dollars. If you are not sure that a plan adequately covers the dental problems of your family, or to be sure you get the network discount, you should talk to your dentist before choosing that plan. For example, most dental plans now cover dental implants, a very expensive procedure. But exactly which parts of the procedure are covered for sure, which options are best, which of these parts or options require plan approval, and how likely a case like yours is to get plan approval, varies from plan to plan. You can call the plan to discuss your case, but the best way to find out which dental plan will cover your implant at least cost to you is to ask your dental surgeon what his patients' experience has been.
In recent years OPM has not allowed most health plans to expand dental benefits. However, OPM has allowed plans to offer "non-FEHB" benefits to plan members, as shown on a special page in brochures. In many cases, extra dental benefits are offered (usually through a panel of dentists who provide discounts for the extra business the plan brings). When these do not involve an extra premium and represent a significant benefit that can be determined from the brochure, we have included their value in our ratings and tables. While they are not part of the OPM contract and will not be enforced by OPM, they are nonetheless plan commitments to you.
The new standalone dental plans give you a good deal more advance assurance about what is covered and how much you are likely to pay than most of the health plans. However, how much each plan will cover depends importantly on whether your expenses are mainly for children or for adults, and whether for preventive and diagnostic services, or for more expensive restorative services (including surgical, endodontic, prosthodontic, etc.).
Our dental benefit tables help you sort this out. First, we provide estimates of the cost to you under each plan that provides dental benefits, organized by type of plan. There are no extra premiums under the health plans, but there are for the standalone dental plans and we show the annual premium cost together with the likely out of pocket cost under low, average, and high usage scenarios. Because the premium cost is a "for sure" expense we include it in each column.
We also show which plans cover roughly how much on average for child preventive, child restorative, adult preventive, and adult restorative services. These estimates are based on a market basket of dental procedures that are among the most common in each category. For example, we assume that children receive the following preventive and diagnostic services through an annual visit: periodic examination, prophylaxis, bitewing x-rays, and fluoride treatment. For adult restorative services, our index includes fillings, extractions, crowns, root canal treatment, periodontal treatment, and dentures. We also provide estimates for some individual procedures. Although the tables show specific percentages, these are rough estimates, based on national average prices. Your dentist may charge more or less. Also, we had to translate varied plan reimbursement approaches into the "percent you pay," and sometimes this is only an approximation. However, these data can steer you towards plans' brochures if there are particular benefits you want to check out in detail for the best coverage.
We also show you the maximum benefit levels (if any) of each plan. Most health plans do not have maximums because their benefits are low enough that they do not face substantial cost exposure. However, most of the standalone plans impose maximum ceilings on what they will pay. If you expect very high expenses, consider a plan with a high or even unlimited maximum, but expect to pay more in premium.
Orthodontic coverage is important to some. All standalone dental plans have a substantial orthodontic benefit, as does the Foreign Service plan. The coverage terms vary, so you should compare them carefully. Especially importantly, some dental plans try to discourage you from joining at the last minute to take advantage of these benefits, often by imposing 12 month waiting periods on eligibility. Many plans, however, impose no waiting periods. Orthodontics is the perfect dental expense for combining a dental plan with an FSA account for expenses the plan doesn't cover. It is also an area where it makes sense to talk to providers about getting the lowest cost, considering which networks and plans they have joined.
In sum, even if you and your family do not need substantial dental work, one of the health plans may be worth several hundred dollars per year, or more, a benefit that costs you no additional premium. The standalone dental plans provide a distinctly better benefit than almost all health plans, but at a premium cost that largely offsets their better benefits. The dental plans make the most sense for persons who are sure they will have moderately or very high dental expenses, want some protection against an unexpected expense, and like the predictability of paying a regular premium and reducing wide fluctuations from month to month in what they may pay.
Before selecting a dental plan, be sure to check with your family dentist as to which plan(s) he or she affiliates with. Our estimates assume that you use network providers. If you choose an out of network provider, you lose the network discount. These plans are good buys only when you use network providers.