A membership plan is not insurance

Practice membership plans have spread quickly, and most of the writing about them is produced by the practices selling them. So here is the version with the disadvantages left in.

They are not the same kind of thing

Dental insurance is a contract with a third party who reimburses part of a fee. A membership plan is a direct agreement with one practice: you pay them, they provide a defined list of care, and nobody else is involved. That difference produces everything else.

The three insurance mechanics worth understanding

The annual maximum

Most PPO dental plans cap what they will pay in a calendar year — commonly between $1,000 and $2,000. That figure has barely moved since the 1970s, while fees have not stood still. A single crown can consume a third of it. If you need a crown and a course of periodontal treatment in the same year, you will hit the ceiling and pay the rest yourself regardless.

The waiting period

Plans commonly impose six to twelve months before major work is covered. This is why people are advised to enrol long before they need anything, and why enrolling because a tooth has just broken rarely helps.

UCR

Usual, Customary and Reasonable is the fee level your insurer has decided is normal for your ZIP code. Reimbursement is calculated against that number, not against what your dentist charges. Two practices with identical fees can leave you with different out-of-pocket costs depending entirely on how a plan sets its UCR — and the schedule is not usually published. This is the single biggest reason we will not estimate what your insurer will pay you.

What a membership plan removes

No annual maximum, because it is not paying claims. No waiting period, because there is no adverse-selection risk to manage in the same way. No deductible. No claim form. No pre-approval, and no third party forming a view about whether your treatment was necessary.

In our plan, $39 a month covers two hygiene visits, two examinations, all periodontal charting and routine radiographs, and takes 15% off everything else. The periodontal version at $62 covers four maintenance visits a year for a treated periodontitis mouth, because a three or four-month interval is what keeps those mouths stable and a six-month convention does not.

If your employer funds a plan and you use it, keep it. We will tell you so at the consultation.

What a membership plan does not do

It does not pay for treatment anywhere else. If you move, change jobs, or need emergency care on holiday, it is worth nothing. Insurance travels; a membership does not.

It does not protect you against a catastrophic year. A discount is proportional: 15% off a $9,000 plan is $1,350, which is meaningful but is not the same as coverage. Insurance, for all its caps, does put a floor under a bad year in a way a discount cannot.

And it does not make treatment cheaper in the abstract. It makes our treatment cheaper, which is a commercial arrangement as well as a clinical one, and it would be dishonest to pretend otherwise.

How to decide in about two minutes

1. Do you have employer-funded dental cover you actually use? Then keep it. Membership on top means paying twice for the same preventive care.
2. Do you have an HMO or DHMO plan? There is generally no out-of-network benefit at all, so treatment here is self-funded either way, and the membership almost always wins.
3. Are you self-employed, retired, or paying for an individual policy yourself?Compare the annual premium against the plan fee. Individual dental policies often cost more than the membership and still carry a maximum and a waiting period.
4. Do you have a PPO with out-of-network benefits? Run one year both ways. We will help you do it honestly, including the case where your plan wins.

One structural point

Being out of network is not primarily about money for us. Network contracts set the fee, and by setting the fee they set the time. A ninety-minute consultation with a full periodontal chart and a designed cosmetic plan does not fit inside a reimbursement schedule built around volume. The membership plan exists so that patients without benefits are not the ones who pay for that choice.

See what the membership covers ·Fees, financing and how claiming works