Two hearings, 66.8%, and the visit your plan stops paying for
Two Sept. 14–15 hearings put dental and vision market concentration on the record; this issue prices what a periodontal maintenance visit and a frame allowance actually cost you under the 2026 Delta Dental, MetLife, VSP and EyeMed documents, and lists what to ask before booking.
The week of Sept. 14–21 put the business of dental and vision insurance on the record, at two congressional hearings, and the numbers used to open the discussion were blunt. In 2024, the three largest stand-alone dental insurers in each state held a median of 66.8% of group enrollment, ranging from 37.9% to 97.5%; for vision, the median was 77.4%, ranging from 41.2% to 95.5% 1. About one in four Americans had stand-alone dental or vision coverage that year, according to National Association of Insurance Commissioners and Census Bureau figures cited in that report.
None of that changed a co-pay. The four carriers this column tracks — Delta Dental, MetLife, VSP and EyeMed — still publish the same 2026 member terms this week as last week, and nothing in their current documents changes what a cleaning, a maintenance visit, or a pair of glasses costs you through December. What the hearings did produce is a clearer account of how the price of your care gets set, and two rules inside the 2026 documents show exactly where that happens.
Two hearings, one concentration story
The House Judiciary Subcommittee on the Administrative State, Regulatory Reform, and Antitrust held a field hearing on Sept. 14 called "Examining Healthcare Markets: Fraud and Competition." In comments filed for that hearing, the American Dental Association asked Congress to treat dental insurance as part of health care competition, and raised specific practices: network leasing, where a dentist's contracted rates are extended to entities the dentist never signed with; contract and fee-schedule changes that arrive without advance notice; and automated claim review. "Insurers should not use AI as the sole basis for claim denials or prior authorization decisions," the association wrote, asking that automated reviews carry validation, appeal rights and human review 2.
A day later, on Sept. 15, the House Energy and Commerce Committee's Health Subcommittee took up 17 legislative proposals, among them H.R. 1521, the Dental and Optometric Care Access Act. More than 40 states have laws limiting how far an insurer can go in setting fees for services its plan does not cover, but self-funded employer plans governed by ERISA can claim an exemption from those state protections, which is the gap the federal bill would close. The ADA told the committee the concentration data makes the point: in 2024, the three largest dental insurers in each state held a median of 66.8% of group-market enrollment, reaching at least 80% in 11 states 3.
The same hearing covered vision. The American Optometric Association reported that H.R. 1521 mirrors the Senate's Vision Lab Choice Act, S. 1716, and would bar plans from requiring doctors or patients to use optical laboratories owned by the insurer. Rep. Buddy Carter, R-Ga., put the market share at "roughly 85%" of the 220 million Americans with vision benefits, spread across two dominant vision benefit managers 4. The AOA counts nearly 25 states with vision benefit manager laws, and notes that federally regulated plans can sidestep them.
The concentration shows up in GAO's interviews too. Dental industry representatives told GAO that vertical integration in dental insurance is limited. Vision industry representatives described something else: insurers that own provider offices, lens and frame manufacturers, and eyewear retail brands 1.
You can see that last part in a member document. VSP's 2026 brochure for the federal program states in its own footnote that "Visionworks, Eyeconic, and Eyemart Express family of stores are VSP-affiliated companies," and the same brochure pays its largest frame allowance at those stores and at Premier Edge locations 5.
Aetna also dropped its planned administrative fee for out-of-network dentists who wanted paper checks, in Illinois, Oregon and Florida, after state dental associations and the ADA pushed back. Aetna told dentists in two of those states that the earlier communication had been sent in error. The change concerns how practices get paid by Aetna, a separate line from your co-insurance 6.
The maintenance visit is paid against an earlier treatment date
Three codes decide what you owe for gum care, and they are easy to mix up.
A prophylaxis, D1110, is the routine cleaning most people mean by "a cleaning." Periodontal scaling and root planing, D4341 and D4342, is the deep clean performed quadrant by quadrant. Periodontal maintenance, D4910, is the follow-up visit that comes after that treatment. The ADA's Code on Dental Procedures and Nomenclature describes D4910 as a procedure performed following periodontal therapy that continues for the life of the dentition 7.
The two federal dental plans in this comparison count that maintenance visit against the cleaning, and both tie it to a past treatment date:
- MetLife's 2026 federal plan limits D4910 to 4 visits in 12 months, combined with adult prophylaxis, and only after the completion of active periodontal therapy. Scaling and root planing is limited to once every 24 months 8.
- Delta Dental's 2026 federal plan limits D4910 to four in a calendar year, combined with D1110 and D4346, and caps D1110 alone at two per calendar year. Periodontal maintenance is covered only when performed following active periodontal treatment, and scaling and root planing is payable once per quadrant in 24 months. The brochure adds that periodontal pocket charting with the areas, quadrants and teeth involved is required for most periodontal procedures 9.
The ADA's own account of why these claims bounce explains the pattern: some payers will only pay for D4910 when it falls within 2 to 12 months of the scaling and root planing, most require a wait of 8 to 12 weeks after therapy, and when a plan's limits apply, many payers will instead allow payment for an adult prophylaxis, which is a component of the larger procedure. Documentation submitted with the first claim is what heads off the request for more information 7.
Offices are working through exactly this right now. On Sept. 16, a dental office posted in r/DentalInsurance that one of the carriers it is contracted with "has started denying D4910" and that the denials were landing on every maintenance claim where the patient had not had surgery or scaling and root planing in the previous two years 10. Replies from other offices described the same rule with different numbers — one wrote that MetLife started it this year, another that Delta Dental of Massachusetts requires scaling and root planing within the last 36 months. One commenter described the workaround: show at least one D4910 every 24 months back to the most recent scaling visit, and the claim goes through. A follow-up post the same day shared an appeal template the office had built, with the attachments it sends — current and previous X-rays showing bone loss, current periodontal charting with pocket depths and bleeding, progress notes, the denied explanations of benefits, and clean copies of the claims — and a note to reference the claim ID from the original denial rather than from later denials 11.
Those posts are front-desk and office-manager accounts of their own claims, and the frequency rules they ran into are the ones printed in the two plan documents above. The pattern they describe is about dates: the plan's clock starts with the scaling and root planing visit, and a later finding that care is still needed does not restart it.
The same maintenance visit across four 2026 options
Both carriers pay these claims from the same class and at the same in-network shares, which makes the comparison simple to read across. Every column below is an in-network figure for the 2026 federal dental program.
| 2026 option | Your share of the plan allowance for D4910 (Class B) | D4910 frequency rule | Condition | Scaling and root planing repeat rule | In-network annual maximum | In-network deductible | Self-only monthly premium, rating area 1 |
|---|---|---|---|---|---|---|---|
| Delta Dental High | 30% 9 | 4 per calendar year, combined with D1110 and D4346; D1110 capped at 2 9 | Only after active periodontal treatment 9 | Once per quadrant in 24 months 9 | Unlimited 9 | $0 9 | $39.67 9 |
| Delta Dental Standard | 45% 9 | 4 per calendar year, combined with D1110 and D4346; D1110 capped at 2 9 | Only after active periodontal treatment 9 | Once per quadrant in 24 months 9 | $1,500 9 | $0 9 | $22.38 9 |
| MetLife High | 30% 8 | 4 in 12 months, combined with adult prophylaxis 8 | After completion of active periodontal therapy 8 | 1 every 24 months 8 | Unlimited, in and out of network combined 8 | $0 8 | $40.76 8 |
| MetLife Standard | 45% 8 | 4 in 12 months, combined with adult prophylaxis 8 | After completion of active periodontal therapy 8 | 1 every 24 months 8 | $2,000, in and out of network combined 8 | $0 8 | $23.60 8 |
The two carriers land in the same place class by class: 30% and 45% for intermediate work, 50% and 65% for major work 89. The real gap sits inside each carrier, between the two options.
A year with gum disease, priced
Here is what a year looks like for someone on maintenance, using published national averages as the price of each visit and rating-area 1 self-only premiums. Both figures are illustrative: your plan's in-network allowance is usually lower than a practice's cash price, which lowers both the plan's payment and your share.
The four maintenance visits come from a national average of $167 per visit 12, so $668 of care at the member share each option charges. The crown, if you need one in the same year, averages $1,399 for porcelain 12 at 50% or 65%, depending on the option.
| 2026 option | Annual premium | 4 maintenance visits, your share | One crown, your share | Year total |
|---|---|---|---|---|
| Delta Dental High | $476.04 | $200.40 | $699.50 | $1,375.94 9 |
| Delta Dental Standard | $268.56 | $300.60 | $909.35 | $1,478.51 9 |
| MetLife High | $489.12 | $200.40 | $699.50 | $1,388.62 8 |
| MetLife Standard | $283.20 | $300.60 | $909.35 | $1,493.15 8 |
The standard options cost about $206 a year less in premium. One crown at the national average puts $209.85 more on your side of the bill, and four maintenance visits at 45% instead of 30% add $100.20 more, which is why the high options finish ahead in this scenario. A year of two routine cleanings and nothing else reverses that: Class A services carry a 0% in-network share on all four options, so the cheaper premium keeps the money 89.
Two structural details worth knowing before you plan around these numbers. The Delta Standard annual maximum is $1,500 in network, so the plan's $699.50 payment on a crown leaves $800.50 of plan money for the rest of the calendar year. And the four-visit pool counts cleanings and maintenance together, with D1110 capped at two, so a year of four maintenance visits cannot be re-coded as four routine cleanings 9.
Where you buy sets what the frame allowance is worth
Vision plans price the same purchase differently depending on which in-network location you use, and VSP's 2026 federal brochure prints both price points side by side.
| VSP 2026 option | Exam copay | Frame allowance | Over-allowance savings | Contacts (instead of glasses) | Lens options | Frequency | Self-only monthly premium |
|---|---|---|---|---|---|---|---|
| Standard | $0 at Premier Edge, $10 elsewhere in network 5 | $200 on Featured Frame Brands, or any frame at Visionworks and Eyemart Express; $150 standard allowance at locations including Walmart and Sam's Club 5 | 20% off the amount over the allowance and on additional eyewear 5 | $120; fitting and evaluation up to $55 5 | Standard progressive $0; premium $95–$105; custom $150–$175; anti-reflective $41–$85; light-reactive $75 5 | Every calendar year 5 | $7.76 5 |
| High | $0 at Premier Edge, $10 elsewhere in network 5 | $250 on Featured Frame Brands, or any frame at Visionworks and Eyemart Express; $200 standard allowance at locations including Walmart and Sam's Club 5 | 20% off the amount over the allowance and on additional eyewear 5 | $150; fitting and evaluation up to $55 5 | Standard progressive $0; premium $95–$105; custom $150–$175; TechShield anti-reflective $0; light-reactive $0 5 | Every calendar year 5 | $14.56 5 |
EyeMed defines the same mechanic in its member guide: a $100 frame allowance applied to a $150 frame leaves $50 to you. The guide also draws a line worth remembering, stating that its extra discounts — 40% off a second pair, 20% off non-prescription sunglasses — are not insured benefits and cannot be combined with other offers. Out of network, EyeMed members pay at the visit and send an itemized paid receipt with a claim form 13.
For out-of-network care, VSP's federal brochure points members to Member Services for the details rather than printing them 5, so the answer takes a phone call before you order.
One $340 frame, two in-network counters
Take the VSP High Option, a frame on the Featured Frame Brand list at $340, premium progressive lenses, and a coated lens. In network, allowances are applied first and the 20% savings applies to what remains above them 5.
| Same purchase | At a location paying the Featured Frame Brand allowance | At a location paying the standard allowance |
|---|---|---|
| Frame | $340 | $340 |
| Allowance applied | $250 | $200 |
| Balance over allowance | $90 | $140 |
| After the 20% savings | $72 | $112 |
| Premium progressive lenses (midpoint of $95–$105) | $100 | $100 |
| Anti-reflective coating | $0 with TechShield | $40 (midpoint of $21–$65) |
| Your total | $172 | $252 5 |
The same frame and the same lenses, $80 apart inside one plan, before the $10 exam copay that the second location charges and Premier Edge locations do not.
What the same work costs in cash
Cash prices for the same work, for comparison: a cleaning and exam runs $75 to $200, a filling $50 to $450, a root canal $700 to $1,500 and a crown $800 to $2,500 or more at a private practice, with dental school teaching clinics charging substantially less 14. Humana's published averages for the Orlando area put a basic cleaning at up to $109, a posterior composite filling at $217, a molar root canal at $1,175 and a porcelain crown at $1,387, with scaling and root planing at $235 to $303 per quadrant 15. For vision, a basic eye exam without insurance runs $79 to $110 at warehouse clubs, with a contact lens exam and fitting at $125 to $150 and private optometrists between $95 and $250 16.
What to do before the appointment
- Ask which date the plan is using. Before scheduling a maintenance visit, have the office read back the most recent scaling-and-root-planing date on file with the insurer and count how many of the plan's four combined visits you have already used this calendar year.
- Get the number in writing first. Both federal dental plans provide for a predetermination or pre-treatment estimate, and MetLife recommends one for charges over $300 89. The estimate names the allowed amount, the deductible and your share.
- Know the appeal clock before you need it. MetLife's 2026 brochure lets you ask for a review of a claim decision within 180 days of receiving it 8; Delta Dental publishes a disputed claims process in its brochure 9.
- Send the documentation with the first claim. Periodontal charting showing pocket depths and bleeding, X-rays showing bone loss, and progress notes are what payers say they need to assess D4910 when a patient's prior treatment was with a different carrier or old enough to age out of the plan's record 7.
- For glasses, ask for two prices and one document. Request an itemized price for the frame and every lens option at the location paying the higher allowance and at another in-network location, then ask for your written prescription to take elsewhere.
- Say it plainly at the counter. "Before I order, can you tell me which allowance tier my plan applies here, and what the itemized total is with each lens option?" and "If the plan denies the maintenance visit, will you send the periodontal charting with the claim the first time?"
What the hearings left open
H.R. 1521 is a proposal. Its next step would be a subcommittee markup, and nothing in it changes a contract you hold today. The same is true of the ADA's asks on network leasing, advance notice of fee changes and automated denials — they are positions on the record, and the 2026 plan documents still govern what you pay. The 2026 federal brochures set their annual open season for Nov. 10 through Dec. 8, which is the window that produced this year's coverage; the equivalent window for 2027 coverage will arrive with the 2027 documents 9. Until those documents land, the date on your last deep cleaning and the counter you buy your glasses at are the two numbers still in your hands.
References
- 1
- 2ADA calls for greater oversight of dental insurance markets
adanews.ada.org
- 3House committee considers DOC Access Act
adanews.ada.org
- 4
- 52026 VSP FEDVIP brochure
federal.vsp.com
- 6
- 7
- 82026 The MetLife Federal Dental Plan
fedvip.metlife.com
- 9
- 10Denied D4910's
reddit.com
- 11Appeal template for denied D4910s
reddit.com
- 12Dentist Prices: Dental Procedure Cost List
carecredit.com
- 13EyeMed Vision Benefits FAQ
eyemed.com
- 14Access Lower-Cost Dental Care
penndentalmedicine.org
- 15Costs of Common Dental Procedures
humana.com
- 16Costco Eye Exam Cost With and Without Insurance
costcoguides.com
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