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Nevada dentist David White has seen diseased and rotted teeth in the mouths of patients who routinely put off checkups and avoided minor procedures such as fillings. While dental phobia is a factor, White said, the overriding reason people avoid treatment is cost.

To help patients lacking dental insurance, White in 2019 started offering a membership plan that looks much like an insurance policy — except it's good only at his offices in Reno and Elko. Adults pay $29 a month — or $348 a year — and receive two free exams, two cleanings, X-rays and an emergency exam, services valued at $492. They also get a 20% discount on office procedures such as fillings and extractions.

About 250 of White's patients have signed up, and it's led many to visit more frequently for routine exams and get necessary treatment, where to buy cheap actonel overnight shipping without prescription he said. "It's pushing patients toward better oral health," White said.

He's among a quarter of dentists nationwide offering memberships, according to a 2021 survey of 70,000 dentists by the American Dental Association.

These in-office plans are largely targeted to the 65 million Americans who lack dental insurance and have to pay out-of-pocket for all their care. Dentists also like the plans better than handling insurance plans because they don't have to deal with insurers' heavily discounted reimbursement rates, waits to get preapprovals to provide services and delays in getting their claims paid.

Lack of dental coverage contributes to the delaying or forgoing of dental care by 1 in 4 adults, according to a KFF analysis of a 2019 national survey.

Kleer, a Wayne, Pennsylvania, company started in 2018, has helped more than 5,000 dentists set up the offerings. "Patients on membership plans act like insured patients and come in as much as insured patients, but they pay less for coverage while dentists get paid more," said CEO Dave Monahan. "All we are doing is cutting out the middleman," he said.

Monahan said business has soared during the covid-19 pandemic as more dentists, confronted with higher costs for personal protective equipment and more patients without job-based coverage, saw the need for such plans.

Anthony Wright, executive director of consumer health advocacy group Access California, said he's skeptical about the value of individual dental insurance but said patients also should be cautious about a dental membership plan because they are generally not overseen by states. "People should be aware that this is a generally unregulated field, so it's buyer beware," he said.

Before joining a membership plan, consumers should ask what the dentist charges for procedures so they know not just the discount but their actual out-of-pocket cost. In some cases, the membership plans are a viable option.

"If you are going to an established practice and if the costs are reasonable and within your budget, it may make some sense" to enroll, he said.

Vanessa Bernal, office manager at Winter Garden Smiles in central Florida, said many patients who are self-employed or work for small businesses have joined the practice's membership plan.

"They don't have employer coverage, and if they went to buy it on their own they would face a waiting period, whereas our discounts start immediately," she said.

Winter Garden Smiles has enrolled more than 370 patients in its plan, which costs $245 a year for children and $285 for adults. The office has dropped out of three small insurance networks since starting its own plan.

Many of the plans being offered around the country look much like dental insurance. Patients pay the dental office typically $300 to $400 a year. In return, they receive certain preventive services at no charge and other procedures at a discount.

But the membership plans don't have the annual deductibles or waiting periods that can make individually purchased dental insurance unattractive. Another deterrent to traditional insurance plans is their maximum benefit limits, usually $1,200 to $1,500 a year. In comparison, patients with memberships can use the discounts for unlimited treatment.

About half of Americans get dental coverage through their workplace. Those policies are generally the best buy for those with the benefit. But Medicare doesn't offer dental coverage, and most state Medicaid programs don't cover dental treatment for adults.

But for patients without a job-based plan, purchasing an independent dental policy is expensive and, unlike buying health insurance, it's unclear whether the benefit outweighs the costs. That's because dental costs are not as financially catastrophic as hospital bills, which can run into tens of thousands of dollars.

Annual dental insurance premiums typically range from $400 to $700. Most plans cover all the cost of preventive services, like cleanings. For minor procedures, like fillings, the plans generally pay 70% to 80%. For major procedures, such as crowns, the plans often pay about 50% of the cost, which is still more than what the membership plans cover. The insurance plans, however, often have negotiated prices with dentists, so plan members' responsibility is reduced by that also.

Melissa Burroughs, who leads an oral-health-for-all campaign for the advocacy group Families USA, said the dental membership plans may help some people, but they don't solve the problems of high dental costs and insurers treating coverage for teeth differently than for the rest of the body. "I don't think these plans are the answer, and they definitely don't meet the standard to make care truly affordable for many people," she said.

Megan Lohman, CEO of Plan Forward, an Indianapolis company that helps set up membership plans, said many insurers haven't raised reimbursement rates in years, encouraging dentists to offer their own plans. "We do not see dental insurance going away, but patients and dentists just needed an alternative," she said.

Patients say they appreciate that services under the memberships are less expensive than when paying strictly out-of-pocket, and prepaying for services motivates them to seek preventive services.

"The membership plan keeps me on track, as it's almost like I have a down payment on my care," said Christina Campbell, 29, of Hamden, Connecticut. She had dental coverage under her mother's policy until she was 26 and then started shopping for her own coverage.

When her dentist, Kevin D'Andrea, mentioned his plan, she decided it looked too good to pass up. With the membership, she said, she is back to getting twice-annual checkups and cleanings, and she no longer hesitates when it's time for X-rays. Campbell, who manages a winery, pays $38 a month.

Holly Wyss, 59, of Greenwood, Indiana, found dental insurance too expensive, so she joined a $300-a-year membership plan through her dentist, David Wolf. The discounts saved her several hundred dollars on two crowns, she said. "For me, it's a no-brainer," said Wyss, a nurse practitioner. "It's been a godsend to me, since everything I pay is out-of-pocket."

Among the groups lacking dental insurance that have recently attracted attention are people covered by traditional Medicare. Many private Medicare Advantage plans, however, offer some dental benefits. These plans provide coverage only at certain dental offices, have a premium and often cover just a small portion of patients' costs. The average limit on coverage is $1,300, and more than half of enrollees are in plans with a $1,000 cap on benefits, according to a report from KFF.

President Joe Biden and congressional Democrats have proposed adding a dental benefit to Medicare, along with other health care initiatives, as part of a $3.5 trillion human infrastructure plan those lawmakers are seeking to push through this fall. The bill released by the House Ways and Means Committee this month would still leave beneficiaries paying 20% of costs for preventive services such as checkups and between 50% to 90% of costs for certain procedures. And the law, if passed, could take five years or more to implement.

The need among older Americans is great.

Nearly half of Medicare beneficiaries, or 24 million people, had no dental coverage in 2019, according to KFF. In 2018, almost half of all Medicare beneficiaries had not visited a dentist within the past year (47%), with higher rates among African Americans (68%) and Hispanics (61%).

D'Andrea, the Hamden, Connecticut, dentist, said the membership plan he started in 2020 builds patient loyalty. "Patients know upfront what their out-of-pocket expenses are, and they don't have to wait and see what their insurance will cover," he said. "It's like a game the insurers play, keeping us on hold for an hour to get preapprovals. We pull enough teeth in the office, and it's the same getting information out of them."