Dental Insurance

Dental Insurance.  Because some dental problems can be prevented, ongoing maintenance is vital to your long term oral health.  Consistent care can reduce your out-of-pocket costs.  With regular check-ups, problems can be diagnosed early, resulting in simpler and less expensive treatment.

Dental insurance usually covers a higher percentage of routine care and a lower percentage of major care.  Since your dental costs may be somewhat predictable   with routine care, you can budget accordingly.  The way that dental insurance is designed, it generally covers only a portion of the fees for most procedures.  Depending on the carrier you have and the type of benefit plan you choose, that amount will vary.

Predetermination of Benefits. If you have never used your plan before and are unsure what to expect, it is sometimes advisable to submit a treatment proposal to your insurance company before proceeding with elective care.  This can help to determine your eligibility, deductible, services covered, allowable coverage, yearly maximum and co-payment required.

Dr. O’Rielly does not recommend waiting for predetermination of costs for necessary treatment because it could delay the care you need.   In addition, your insurance company is not actually bound to the estimates.

Annual Benefits Limitations.  Your plan probably has a maximum amount they will pay in a given year.  By knowing in advance what and how much your plan allows, you and your dentist can sometimes plan your treatment to maximize your benefits.

8 Things to Consider When You Choose a Dental Plan

1. Does the plan give you a choice about which dentist you will see? When you are restricted to a network of dentists selected by the insurance company, patients often experience a significant change in the level of service and care.  Since regular check-ups reduce the chances of developing dental disease, it's best to have and maintain an established relationship with a dentist you like and trust.  When you select a dentist based on cost rather than care, your experience is less apt to be a positive one.  This can often deter you from receiving the care you need.

2. Who is in control of treatment decisions--you and your dentist or the dental plan?  When there are multiple treatment options for a specific condition, some plans will only pay for the treatment option that is least expensive.  You may end up paying the difference between treatment your insurance is willing to cover and the treatment you really should have.  

This is an important consideration about the role your insurance will play, because cost control measures may have an impact on the type of restorations they will pay for.  When choosing a plan, pick one that allows you the most control over your treatment decisions.

 3. Coverage for diagnostic, preventive and emergency services is another important factor.  Most dental plans provide coverage for preventive work that is essential to good oral health.  No one likes surprises, or the pain associated with emergencies.

The extent of services covered by some plans may have limitations and you may be required to pay the dentist directly for some portion of basic care.  Usually the best plans cover the following services in full, with no deductible or patient co-payment.

Initial Exam:  one time per dentist

Recall Examinations:  twice every year

Full mouth x-rays:  once every 3-5 years

Bite-wing x-rays: once per year

Cleaning (“prophy”):  two times per year
 
4. What routine treatments are covered by your insurance? How much will you have to pay?   A wide spectrum of treatment comes under the heading of ‘basic restorative’.  Most insurance plans will cover 70 to 80 % of this type of treatment, while patients are responsible for remaining costs. 

Some examples of routine treatments include:

Restorative care:  composite resin fillings

Endodontics:  root canals treatment and the removal of tooth nerves

Oral Surgery:  tooth removal (which does not include bony impaction) and minor surgical procedures such as drainage of minor oral infections.

Periodontics:  treatment of the early stage of periodontal disease including scaling, root planing and management of acute infections
 
When you sign up for any dental insurance plan, be sure you understand what routine dental care is covered and what percent of costs will come out of your pocket.

5. What major dental care is covered by the plan? What percentage of these costs will you be required to pay?  Most insurance plans are not generous when it comes to paying for major dental work because it is more expensive.   Usually, plans cover less than 50% of major treatment costs.

Generally, the maximum within a given year will limit the number of procedures allowed.  Understanding these restrictions will help you to decide on the plan that’s right for you.  It can become an important factor in making sure that you and your dentist are in charge of your treatment planning.

Major dental care may include:

Restorative care: individual crowns, gold restorations such as bridges

Oral Surgery: complex oral surgery procedures, removal of impacted teeth

Periodontal care: treatment of involved conditions caused by periodontal disease

Orthodontics: braces, retainers, diagnostic supports

Dental Implants:  placement of posts or crowns

 Making the Most of Your Insurance Plan

Preventive care is always the best strategy for dental health as well as maximizing your dental insurance. Regular check-ups with cleanings and good home hygiene is really the best insurance of all.

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Glossary of Terms

UCR stands for usual, customary and reasonable.

Usual fees are the fair prices charged for a given dental service.

Customary fees are determined by the insurance company based on the range of usual fees charged by dentists in a given locale.

Reasonable fees are justified by the particular circumstances of a case.

Table of Allowances is the fee schedule for each dental procedure.

Pre-determination or pre-authorization is an estimate of the portion of the treatment plan the insurance company will cover.  The patient will be responsible for the rest.

Freedom of Choice is provided in PPO plans that allow full benefits for treatment provided by the dentist of your choice.

Limitations refers to the coverage for certain procedures or else the number of times a procedure will be covered.

Exclusions deny coverage for certain procedures.

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Frequently Asked Questions

Q: Why does my dental insurance pay only 50% of the charges when my policy says it will pay 80%?

A: There are several possibilities.

1. If your benefits are based on UCR calculation, it might indicate that the UCR data is out of date or not specific to your local area.

2. If you belong to a PPO, your full benefits will be paid only if you seek care from one of the contracting dentists.

3. If your benefits are calculated using a Table of Allowances, the table might be out of date or set at an unrealistically low amount.

4. If your policy provides for the least expensive treatment, you may be reimbursed the stated percentage of the fee for the lesser  treatment option.

Q: Why can't I go to any dentist?

A: Many employers will contract with a network of dentists, known as preferred providers, to limit the costs of insuring employees.   As a result, your dental benefits through your employer might only be available by seeking care from a dentist who has a contract with that company.

Q: Is my dentist overcharging when my insurance company reimburses me for only part of the dental fees?

A: Many insurance companies base their fee allowances on UCR rates, however these allowances can vary from company to company.  While these reimbursements are generally based on what the majority of dentists in your area charge, figures used to calculate benefits may be out of date.   They may also not be specific to your location. When the insurance company uses a Table of Allowances, benefits assigned to specific dental treatment are minimal and offer minimal coverage.  This may not reflect actual costs.

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For assistance with questions about your individual dental insurance carrier or benefits, contact Kelly at kelly@myholisticdentist.com.
Kelly can also be reached at 760-632-1304.