Facts about your Dental Insurance

According to the Centers for Disease Control and Prevention, about 27% of American adults have untreated cavities, while over 50% suffer from some level of gum disease. Unfortunately, many of these people fail to seek treatment, because of affordability issues.

Dental insurance can help offset the cost of dental care by paying for restorative treatments, along with preventative exams that catch minor problems in their infancies. To get the most from your benefits, however, it’s important for you to understand your policy.

Understanding Key Terms

Dental plans include basic terminology relating to out-of-pocket costs, limitations and exclusions. To better understand your plan, it helps to know the meanings of these key terms

Deductible:

Similar to auto insurance, a dental plan may include a set amount you must pay before you receive any benefits.

Maximums:
This is the most money a plan will provide for dental care during a specified benefit period (usually one calendar year). Once you reach this cap, you will have to pay any treatment costs for the remainder of the period.

Coinsurance:
In relation to fee-for-service benefit plans, the coverage will include a set percentage of the treatment cost, leaving you responsible for the remaining balance. Coinsurance refers to the part that you pay once you’ve reached your deductible.

Annual Maximum:
The total amount an insurance plan will pay for an individual enrollee’s dental care in a given period, usually a full calendar year.

Lifetime Maximum:
The total cumulative amount an insurance plan will pay for an individual enrollee’s dental care for the life of the plan. Lifetime maximums typically apply to specific services, including orthodontic treatments.

Pre-Treatment Estimates:
For especially extensive or costly dental treatments, our dental office can submit a pre-treatment estimate to your insurer. This can give you an idea of how much you will end up paying out-of-pocket. However, it is still not a guarantee on what the insurance will actually cover.

Exclusions And Limitations:
While dental plans can reduce the financial burden of treatment, they don’t usually extend to every single dental need. Most plans limit the number of cleanings you can get in one year, while others may refuse to cover certain procedures, even if they are recommended by your dentists. You should carefully identify any potential limitations or exclusions before you settle on any one plan.

Open Access:
A kind of dental plan that allows enrollees to visit the dental professional of their choice. Some open access plans will also allow enrollees to seek treatment from a specialist without having to obtain a referral from a primary care dentist.

Closed Network Plan:
With these types of insurance plans, coverage is limited to a pre-selected or pre-assigned network of dentists. In other words, to receive benefits, you must visit a dentist from a specified list provided by the insurance company. Due to these limitations, it’s important for you to verify with your insurer that the dentist you want to see is a part of your network before scheduling an examination or dental procedure.

Waiting Period:
A dental insurance waiting period is a set period of time before you can receive full coverage for some specific dental procedures. Waiting periods vary based on your plan and can range from a few months to over a year. Waiting periods are primarily for basic and major dental work, and nearly all dental plans cover preventive dental care right away. Knowing which procedures require a waiting period before you schedule a visit can help you prepare and avoid unexpected costs. Here are some of the most common categories for dental insurance waiting periods.
Waiting Period Types:

Preventive: Most dental insurance plans do not require a waiting period for preventive care. That means you and your family may receive exams, cleanings, x-rays, and fluoride treatments as provided in your plan.
Basic: Some basic procedures may have a three- to six-month waiting period. Basic procedures typically include fillings or non-surgical extractions.
Major dental work: Major work may have a three-month to one-year waiting period. Major work generally includes crowns, bridges, and dentures.

Missing Tooth Clause:
A missing tooth clause means the dental insurance company will not cover the costs of replacing the tooth if the tooth fell out or was extracted before the current dental coverage started.

Preauthorization:
Some insurers insist on approving specific recommended treatments before agreeing to pay for them. If there’s any doubt, call your insurer to verify coverage before you schedule a procedure.

Downgrades:
A downgrade or dental insurance downgrade occurs when insurance companies elect to pay for the least expensive procedure even if it is no longer considered the standard of care (for example amalgam or silver fillings). In this situation, the patient will receive tooth colored composite fillings but the insurance company will only pay to cover for amalgam fillings. This will result in an increased out of pocket portion for the patient. Filings and crowns are often downgraded.

Reimbursement Levels:
A fee-for-service plan will offer certain categories of coverage, with each being tied to a specific percentage. For instance:

Preventative and diagnostic procedures are usually covered at 80% to 100%. From an insurer’s point of view, this gives policyholders incentives for getting routine cleanings and checkups, which reduce the likelihood of more costly procedures down the road.
At the next level are basic procedures which are reimbursed at a slightly lower percentage, followed by major procedures, which receive an even lower reimbursement percentage.
Preventive and diagnostic services: A specific category of dental services, which typically include routine cleanings, oral evaluations, fluoride treatments and X-rays. The same coinsurance percentage will usually apply to all preventive and diagnostic services

What is Considered Basic Dental Care?

Most dental plans will offer 80% coverage for basic dental services, including fillings, non-routine x-rays, extractions, sealants and certain periodontal treatments. The typical plan will also cover the entire cost of preventive procedures, such as oral exams, routine cleanings, routine x-rays and sealants. On the other hand, some dental treatments, such as crowns, dentures and bridges, would not be considered basic dental care. In turn, the typical dental plan will only offer 50% coverage or less for these procedures.

If your insurance changes during the course of your treatment (for example orthodontics or dental implants) then your dental coverage may change.

OUR OFFICE POLICY REGARDING DENTAL INSURANCE

If we have received all of your insurance information on the day of the appointment, we will be happy to file your claim for you. You must be familiar with your insurance benefits, as we will collect from you the estimated amount insurance is not expected to pay. By law your insurance company is required to pay each claim within 30 days of receipt. We file all insurance electronically, so your insurance company will receive each claim within days of the treatment.

PLEASE UNDERSTAND that we file dental insurance as a courtesy to our patients. We do our best to find your information and your coverage but sometimes your insurance company will limit the amount of information they give us. The best way to know if you are truly in network with our office is to personally call your insurance company and verify that we are in network.

We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment. We at no time guarantee what your insurance will or will not do with each claim. We also can not be responsible for any errors in filing your insurance. Once again, we file claims as a courtesy to you.

Fact 1 – NO INSURANCE PAYS 100% OF ALL PROCEDURES
Dental insurance is not like medical insurance. It is more like a coupon or a discount plan. Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90%-100% of all dental fees. This is not true! Most plans only pay between 50%-80% of the average total fee. Some pay more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for coverage, or the type of contract your employer has set up with the insurance company. Unlike medical insurance, dental insurance has a maximum benefit per year. Once you reach that maximum benefit, all dental treatment will be out of pocket.

Fact 2 – BENEFITS ARE NOT DETERMINED BY OUR OFFICE
You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist’s actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist’s fee has exceeded the usual, customary, or reasonable fee (“UCR”) used by the company. A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable, or well above what most dentists in the area charge for a certain service. This can be very misleading and simply is not accurate. Insurance companies set their own schedules, and each company uses a different set of fees they consider allowable. These allowable fees may vary widely, because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily chooses a level they call the “allowable” UCR Fee. Frequently, this data can be three to five years old and these “allowable” fees are set by the insurance company so they can make a net 20%-30% profit. Unfortunately, insurance companies imply that your dentist is “overcharging”, rather than say that they are “underpaying”, or that their benefits are low. In general, the less expensive insurance policy will use a lower usual, customary, or reasonable (UCR) figure.

Fact 3 – DEDUCTIBLES & CO-PAYMENTS MUST BE CONSIDERED
When estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume the fee for service is $150.00. Assuming that the insurance company allows $150.00 as its usual and customary (UCR) fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Out of a $150.00 fee they will pay an estimated $80.00 leaving a remaining portion of $70.00 (to be paid by the patient). Of course, if the UCR is less than $150.00 or your plan pays only at 50% then the insurance benefits will also be significantly less.

MOST IMPORTANTLY, please keep us informed of any insurance changes such as policy name, insurance company address, or a change of employment.