Group Dental Insurance is a benefit that can be offered by an Employer to their Employees and their Dependents. The plan can either be Employer Sponsored Dental coverage (meaning the company pays a portion or all of the premium) or Voluntary Dental Benefits (meaning the Employee voluntarily enrolls and pays for coverage or declines coverage.) In either case, the Company can deduct the premiums paid for employees (non-owner employees), and Employees can pay their share of the premium on a pre-tax basis with a P.O.P. (Premium Only Plan.) The Group Dental benefits can be done with the same insurance carrier that provides the health insurance or with another insurance carrier, and the plan does not have to accompany any medical plan (otherwise known as a STAND-ALONE Dental plan.)
Similar to health insurance plans, Group Dental Plans can be offered with a PPO network, HMO network, or Traditional insurance (no network - you can go to ANY dentist.) Some dental carriers will allow an Employer to offer multiple plans to the Employees and let them pick and choose the Small Business Dental Insurance plan that best suits their needs. (There are some rules and restrictions on number of plans offered.) Most insurance plans cover three levels of services: 1) Preventative, 2) Basic, and 3) Major Services. Some, but not all, will offer coverage for Orthodontia (a 4th level of coverage.) Typically you will see plans covering Preventative at 100%, Basic at 80% and Major and Ortho at 50%. In addition, most plans have an annual maximum benefit that the insurance will pay out to providers or $1000, $1500, $2000 or $2500. This annual maximum is for each person covered on the plan. If the Employer decides to offer Group Dental Insurance for the first time, you will typically see a 1-year waiting period before Major and Ortho services are covered. The same rule applies to new hires getting on the group; they will have to wait 1-year to have these services covered.
As of January 1st 2014, the ACA (Affordable Care Act) requires all small group medical plans to cover Pediatric Dental coverage or add this benefit. While dental is not usually covered under a major medical insurance policies, some insurance companies did decide to "embed" this benefit into their health plans to make sure their members were compliant with the law. (UnitedHealthcare® included Pediatric Dental in many of their medical plans.) Other medical carriers agreed to certify to the gov't that his was offered and if waived, the employees signed off that they have the adequately required Pediatric Dental coverage. (Blue Cross of IL has a pediatric dental that was automatically added to their small groups if the group did not offer their Group Dental Plans to employees. The Employer could sign a form if they had this coverage with another insurance carrier; the employees could also waive this individually if they had adequate coverage elsewhere i.e. spousal coverage or individual dental policy.)
Remember, companies with 50 or more F.T.E. EE's (Full Time Equivalent Employees) are required to offer HEALTH INSURANCE to full time Employees (beginning in 2016, and in 2015 for companies with 100 plus F.T.E. EE's.) They do NOT have to offer Small business Dental Insurance, but must certify that all employees have the adequate Pediatric Dental coverage.
CB Health Insurance is licensed with top carriers in Illinois, such as Delta Dental, Guardian, Humana, and others. Please contact our office for more information or a quote on either Employer Sponsored or Voluntary Dental Benefits.
PPO - Preferred Provider Organization/ HMO - Health Maintenance Organization:
Similar to Group Health Insurance, group Dental Insurance can operate using a LIST of dentists that contract with an insurance company. In a PPO plan, the patient (or employee) can go IN or OUT of the PPO network. By choosing to see a Dentist IN the network, the Employee knows what to expect in terms of coverage. Because the Dentist has signed a contract to provide services and accept certain reimbursement levels, they cannot 'balance bill' the patient over the allowable reimbursement amount. So choosing an IN-network provider gives some reassurance of a lower over all out of pocket and no 'surprise billing'.
With many Group Dental PPO plans, the Reimbursement amount for OUT OF NETWORK PPO providers is based on a percentage of "Usual and Customary Fees". The higher the percentage, the better the reimbursement and less likely the Employee will be stuck with a bill bill. Common reimbursement can be 80-90% of Usual and Customary charges, sometimes referred to as reasonable and customary charges.
In the case of an HMO, there are no Out of Network benefits; the Employee will need to CHOOSE a primary Dentist to seek treatment. The employee must get referrals from the primary dentist to see a specialist, and if they go out of the network of dentists, there is no coverage. This may seem more restrictive, but HMO Group Dental plans can offer Employees lower premiums and higher benefit coverage levels, provided the Employee can work within in the network.
Under the Affordable Care Act, individuals and small groups (2-50 employees) must have health insurance coverage for all 10 essential health benefits, including Pediatric dental. 'Pediatric' under the law is defined as any child under the age of 19. The coverage cannot have any waiting periods for services and must have an out of pocket maximum per child no more than $700/year.
Please NOTE: Under the health care law, most people must have health coverage or pay a tax penalty. But this isn't true for dental coverage. You don't need to have dental coverage, even for children, to avoid the penalty. Pediatric Small Business Dental Insurance must be available to you, but you do not have to buy it. Also, employer groups under 50 full time employees do not face penalties for not offering insurance, health or dental.