Understanding Your Dental Insurance
At first glance, dental insurance is similar to health insurance. Then, it gets a little tricky. This overview can help eliminate the confusion.
Like with health insurance, dental insurance requires you to pay premiums to an insurance company, unless they’re deducted from your paycheck by an employer. Dental insurance also has deductibles and copays.
Your deductible is a yearly fee you must pay before your insurance starts paying your treatment claims. The dental office generally collects this during your visit. There can be a family and individual deductible. For example, if you’re a family of four and your family deductible is $200, each family member will pay $50, until the $200 is met. (You typically don’t have to pay a deductible during diagnostic or preventive visits (routine cleaning, x-rays, exams), only you have an actual treatment performed.)
Your copay is the percentage of the treatment you share in paying with your dental plan. If a treatment costs $100 and your plan covers 80%, you pay $20 and they pay $80.
Also, like with health insurance, it’s important that you find a dental provider that not only accepts your insurance, but also is contracted with your insurance company. Contracted dentists agree to the plan's discounted fee schedule, which will cover more treatments and save you money. Non-contracted dentists are usually paid according to their usual and customary fees (UCR).
There will also typically be a maximum annual amount that your plan will spend on your care. This is the total amount your insurance company will pay your provider during a 12-month period. Your insurance covers a percentage of each treatment, and will continue to pay on treatments until they reach the maximum within the time allowed. If you don't use your maximum amount, you lose it.
Similar to the maximum annual amount your plan will spend on your care, your plan will likely have a cap on the number of times (or frequency) you can have a certain procedure performed during your coverage year. For example, while many plans allow two cleanings each year, it’s important if you can have them anytime or if you can only have one every six months. If you use services more often than your plan allows, you will receive a bill for those services.
Those are all the similarities between health insurance and dental insurance. Here are the differences.
COVERAGE BREAKDOWNS
Dental insurance typically covers three different areas of care:
Example Plan
Preventive care services include cleanings, exams, and X-rays, as well as fluoride treatment for patients age 18 and younger. Your insurance will typically cover 100% of these costs.
Basic services like fillings and non-surgical extractions. Your insurance will typically cover 80% to 100% of those costs, and will generally pay for one filling on the same tooth every two years. (Note: Many plans will not pay for all-composite fillings, and will downgrade any fillings done on posterior (back) teeth to amalgam (black/metal) fillings. You will be responsible for the difference in fees between the two types of fillings.)
Major services means virtually everything else. Your insurance will typically cover between 50% and 80% for these services. There may also be exclusions.
Your policy might cover additional categories, like orthodontia or dentures, with different coverage limits. You might want to shop around for another plan if your doesn’t at least partially cover crowns, root canals, oral surgery, panoramic X-rays, or periodontitis treatment.
Dental insurance typically doesn’t cover cosmetic dentistry or teeth whitening. Some plans might cover orthodontics (braces) at a smaller percentage.
OTHER GUIDELINES
Dental insurance plans also have other general and specific rules that may or may not affect the services you need.
Here are the most common:
Many insurance plans have a waiting period on major services. While you can use your plan anytime to cover basic or preventive services like X-rays, cleanings, or fillings, you’ll have to wait a period of time to use your plan for major services like crowns or bridges.
Many plans also have a “prior placement” policy for crowns, which means that if you need to replace an existing crown with a new one, the old/faulty crown can’t be less than 5 years old. Also, many plans will only pay for certain types of crowns (like metal or porcelain over metal), and will require you to pay your copay plus the difference in cost for a cosmetic rated crown, like full ceramic or zirconia.
If you had a tooth extracted longer than 6 months ago and left the spot open because you couldn’t afford a bridge or an implant, there’s a good chance you’ll have to pay for the entire treatment per your policy’s bridge missing tooth clause.
*While most dental insurance is similar, no two plans are the same. This article is intended to provide information on common coverages through an employer based plan and may not apply every every circumstance. Individual based plans are often different. If you are shopping for a new plan, look for one that best serves your family’s specific needs.
If you have any questions about your current dental coverage, be sure to contact your insurance company.
The staff at White Oak Dental will also gladly help you determine which treatment options will best match your needs, coverage, and budget.
Do you have questions about the services offered at White Oak Dental? Click here to get answers or make an appointment.
