3.5 Dental and Vision Plans

Why Dental and Vision Are Tested Separately

The content outline lists dental and vision as named products under Other Policies, and they are tested because their benefit architecture is genuinely different from major medical. Medical coverage protects against catastrophic cost with a deductible, coinsurance, and an out-of-pocket maximum that caps the insured's exposure. Dental does close to the opposite: small, predictable, high-frequency claims with an annual benefit maximum that caps the insurer's exposure. Reverse that in your head and most dental questions answer themselves.

Dental Plan Design

The three procedure classes

The 100/80/50 ladder is the single most-tested dental fact. Preventive care is covered in full, and often outside the deductible, because cleanings and exams are far cheaper than the restorative work they prevent — the plan is buying down future Type II and Type III claims.

Annual maximum, not out-of-pocket maximum

A dental plan pays up to an annual benefit maximum — commonly $1,000 to $2,500 per covered person per benefit year. Once the plan has paid that amount, the insured pays 100% of further charges for the rest of the year. There is no out-of-pocket maximum protecting the insured. A candidate who assumes dental works like medical will answer this backwards.

Deductibles are small — often $50 individual and $150 family — and typically apply once per benefit year to Type II and Type III services only.

Scheduled vs. nonscheduled

• A scheduled (basic) plan lists a fixed dollar allowance for each procedure. It is predictable for the insurer and leaves the insured exposed to the balance when charges exceed the schedule.
• A nonscheduled (comprehensive) plan pays a percentage of usual, reasonable, and customary (URC) charges by procedure class. This is the 100/80/50 design and the more common structure.
• A combination plan pays scheduled amounts for some services and URC percentages for others.

Controlling adverse selection

Dental coverage is unusually exposed to adverse selection: people who know they need a crown enroll, use the benefit, and drop the plan. Insurers respond with:

• Waiting periods — often 6 months for basic and 12 months for major services, and 12 to 24 months for orthodontia
• Missing tooth clauses — no benefit for replacing a tooth lost before coverage began
• Least expensive alternative treatment (LEAT) provisions — the plan pays the cost of the cheapest adequate treatment, and the insured pays the difference for an upgrade
• Predetermination of benefits — the dentist submits a treatment plan in advance for work over a stated dollar amount, so the patient learns coverage before treatment
• Minimum participation on group dental, and rate penalties for late entrants

Vision Plan Design

Vision plans are frequency-and-allowance products rather than percentage-coinsurance products. A typical benefit:

The distinction the exam tests is routine vs. medical. Routine vision — refractive exams, glasses, contacts — belongs to the vision plan. Medical eye care — glaucoma, cataract surgery, diabetic retinopathy, eye injury — is a major medical claim, not a vision-plan claim. Laser vision correction is typically excluded or offered only as a negotiated discount.

The ACA Line

Pediatric dental and pediatric vision are two of the ten Essential Health Benefits, so ACA-compliant individual and small-group plans must cover them for children (pediatric dental may be offered through a separate stand-alone plan in the Marketplace). Adult dental and adult vision are not Essential Health Benefits. That is why adults buy them as separate products, and why both commonly qualify as excepted benefits — a status that keeps them outside many ACA and HIPAA group-market requirements when offered under a separate policy or with separate election and premium.

Original Medicare likewise does not cover routine dental, vision, or hearing; those are among the most common supplemental benefits Medicare Advantage plans use to attract enrollment.