Healthcare

Understanding dental plan cost and coverage details for SHOP

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As you review your dental plan options, you can narrow your results by cost and coverage details. Here’s a list of common terms you’ll see when narrowing your dental plan results.

Dental plan costs

Deductible

The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Premium

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly, or yearly.

Dental plan coverage details

Dental plan types

1. HMOs (Health Maintenance Organizations)

HMOs may limit coverage to providers inside their networks. A network is a list of doctors, hospitals, and other health care providers that provide medical care to members of a specific health plan. If you use a doctor or facility that isn't in the HMO’s network, you may have to pay the full cost of the services provided. HMO members usually have a primary care doctor and must get referrals to see specialists.

2. PPOs (Preferred Provider Organizations) and POS (Point-of-Service plans)

These insurance plans give you a choice of getting care within or outside of a provider network. With PPO or POS plans, you may use out-of-network providers and facilities, but you’ll have to pay more than if you use in-network ones. If you have a PPO plan, you can visit any doctor without a referral. If you have a POS plan, you can visit any in-network provider without a referral, but you’ll need one to visit a provider out-of-network.

3. Multi-State

Multi-State Plan options are consumer-friendly insurance choices backed by the experience of the U.S. Office of Personnel Management (OPM), the same agency that oversees health insurance for Federal employees.

4. Plans with a National Provider Network

Plans with a national provider network let you to see providers nationwide. You can get health services at a lower rate if you use the doctors, hospitals, and specialists within the plan’s network.

In tiered provider networks, health insurance companies place providers, like doctors and hospitals, into tiers (usually just 1, but sometimes 2 or 3). You may pay different levels of copayments, coinsurance, and/or deductibles depending on the tier of your health care provider. The lower the tier, the less you’ll pay for a covered service or supply.

5. Indemnity

These insurance plans don’t have a network of providers they contract with. You’ll receive covered benefits from any doctor you choose.

6. Referral needed

Some plans require you to have a referral: a written order from your primary care doctor to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.


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