What is open enrollment?
It is the annual window (typically November 1–January 15) when you may select new health insurance and supplemental (dental and vision) insurance plans.
Note: Refer to your employer, individual, or federal program for the specific dates when you may participate.
Why the short window and why only once a year?
Open enrollment gives insurance companies stability and greater control over how they pay for your treatment. They do not want patients enrolling or changing plans after learning of a diagnosis or needed procedure.
What are some exceptions, known as Qualifying Life Events (QLEs)?
Life changes may allow you to enroll outside of the open enrollment period. These may include:
- Pregnancy
- Childbirth
- Marriage
- Divorce
For a full list, please see your insurer’s website or healthcare.gov/screener.
If you change employers outside of open enrollment, there will be a special enrollment period to join an employer’s plan during an allowed time frame, typically 30–60 days.
Keep in mind, when you choose a health insurance plan, it does not automatically enroll you in dental or vision plans unless you specifically sign up for those supplemental plans separately.
Health insurance will not cover any services in dental practices unless it is medical in nature such as trauma surgery or pathology.
Now, since we are a dental practice, here are some considerations we recommend when choosing a dental insurance plan.
What are the two categories of dental insurance plans?
When patients call to schedule, we always ask if their plan is a PPO or an HMO. Here are the meanings and core differences between the two. It is important you consider all of these factors when deciding the best plan for your individual and/or family’s needs.
PPO: Preferred Provider Organization
- There may be higher premiums, but there is more flexibility when finding a provider. (Note: It is important that you find a provider who you connect with and will provide you with the best quality treatment. Not all offices are equal, nor do they all use the same high-quality materials and processes.)
- Patients may select any dentist, in-network or out-of-network.
- No referral is needed for specialists.
- Insurance reimburses a percentage of fees based on how they categorize the dental codes (e.g. preventive, basic dental work, major dental work, etc.).
- Plans typically have a deductible and an annual maximum.
- The term “Preferred” in "Preferred Provider Organization” does not speak directly to the quality of the doctor.
HMO: Health Maintenance Organization
- HMOs typically offer lower premiums but far fewer choices in providers.
- Patients may only select from a contracted list of providers.
- While there may be no deductible or maximum as with a PPO, there are fixed copays.
- You must stay in the network of doctors to use your benefits.
- Referrals to specialists are required.
Looking at the cost of PPO and HMO plans, is dental insurance worth it?
Here is the frustrating, but honest non-answer: It depends.
For PPOs, dental insurance is like a gift card. Even once you hit your deductible, you will have an annual maximum of benefits that you can use each year. Annual maximums typically range from $1,000 to $2,000 per person per year. Once the benefits have been used, patients will pay out-of-pocket until their benefits reset regardless of your provider or treatment.
The question comes down to– What are you paying monthly, and how does that compare to the benefits you will receive?
For HMOs, your provider, treatment, and copays will be dictated by the insurance company. And, it is important to explore how the copays will compare to your monthly payment for the plan.
Are all dental services covered by every plan?
No. Dental services are determined by specific plans, not insurance companies. So be sure to evaluate each plan individually.
Each dental procedure has an assigned dental code that starts with “D”. If you know you may need treatment in the coming year, for example, and an occlusal guard code D9944 (widely known as a nightguard), you can see if it is listed as a covered benefit before enrolling.
Explore treatment options such as Restorative Dentistry, Cosmetic Dentistry, or TMJ Treatments to see how your plan may apply.
Are dental and orthodontic benefits the same?
No. While orthodontic benefits are offered under dental insurance plans, not all dental plans have them. And, they are considered separate benefits with different limits. The amount you have to spend on orthodontics will be different from your dental benefits. Here are some important points to note:
- Orthodontic benefits range from $1,000-$2,500. They do not renew annually. Orthodontic benefits are considered “lifetime benefits” so you get one set amount to use for the entirety of the time that you are on the plan.
- Are orthodontic benefits paid like dental benefits? No. They are reimbursed to the patient or paid to an office over the timeline of the treatment. They are typically paid monthly or quarterly, not at once as for dental procedures.
- If you change plans during orthodontic treatment due to a new job, the benefits do not typically carry over. And if you must change plans, ensure there is an orthodontic continuation clause in your new plan to see that you still get benefits for your current treatment.
- While some plans look like they have orthodontic benefits, read the fine print as many plans have age limits (for example: up to 19 so only children are covered).
Helpful Tips
Lastly, here are some miscellaneous points that we put together that our patients are frequently surprised by, but are so important to note:
- Out-of-network dental practices are known for providing high-quality treatment as it is dictated by the patient’s needs, not the insurance restrictions. Most out-of-network offices still file claims on your behalf and help you maximize your benefits.
- Typically, dental insurance companies will list in plan descriptions that two cleanings and exams per year are covered. However, this is IF you have remaining benefits. If you have dental work that is prescribed, then you will pay out-of-pocket for any costs that are not covered by your annual maximum, even at in-network practices. Some patients, especially those with periodontal disease or gingivitis, need more regular cleanings to keep their oral health from relapsing. In this case, patients will likely pay for a third and/or fourth cleaning out-of-pocket.
- Dental insurance can still deny payment for treatments even if they are covered under the plan. Nothing is guaranteed. If this is the case, work with your dental office and ask them to provide a narrative or appeal in response to the insurance company to fight for your benefits.
Insurance is complicated—but understanding it helps you make the most informed choices for your oral and overall health.
You are welcome to email me at liza@white32dc.com for feedback on any specific dental plans or if you need help interpreting your benefits.
One day, there should be an insurance life skills course! But, until then, we got you!
Learn More or Schedule a Visit
White32 Dental makes it easy to use your benefits or explore flexible Payment Plans and Pay with Cherry options if you’re uninsured.
📞 (202) 519-7410
📧 team@white32dc.com
📍 3301 New Mexico Avenue NW, Suite 323, Washington, DC 20016