FAQ – Dental Insurance

Understanding Dental Insurance

Dental insurance can be confusing. There are different plans, co-pays, deductibles, and benefits. It can be difficult to understand  whether a certain dental service is covered under your dental insurance benefits or not. Not only do you have to understand your plan, but also how each procedure is billed. This can be overwhelming and, in some cases, confusing. While every dental insurance plan is different, we will answer some of the most common questions about dental insurance benefits.

Frequently asked questions - Dental Insurance - Fairview Dentist

What is Dental Insurance?

To keep your teeth in tip-top shape and have a healthy smile, you need to take good care of them. One great way to do this is with dental insurance where they pay a percentage of the cost of your dental care every year.  Each plan is different in terms of coverage, which dentist you can see, and how much it cost. If you’re unsure if we’re in-network with your dental plan, please contact us today!

Why aren't all of my dental treatment costs covered?

The dental coverage of your treatment will vary from plan to plan. A typical dental health insurance plan generally covers dental procedures from three categories, where they pay 100% for preventive care, 80% for basic procedures, and 50% for major procedures.

  • Diagnostic and preventative procedures – These types of procedures are generally covered 100% and include checkups, routine cleanings, exams, x-rays, and fluoride treatment. You should receive two cleanings and two exams during each annual benefit period for your preventive care.
  • Basic Procedures – Procedures that fall into this category are usually covered at 80% and include fillings, simple extractions, root canals, and some periodontal work. Depending on your plan, basic procedures may be associated with a waiting period, frequency limitations and or deductibles for certain types of dental services.
  • Major Procedures – Major procedures, or major services are covered at 50% and may include crowns, bridges, dentures, and complicated treatments. Like basic procedures, there may also be a waiting period, frequency limit, and or deductibles for certain services. If you need extensive restorative dental work, even patients with insurance can end up paying the majority of their care due, depending on your dental policy.

What if my plan says it covers 100% of exams and certain other procedures?

In most cases, dental insurance policies allow a specific dollar amount and agree to apply 100% of that allowed amount to specific procedures. However, if your dental treatment costs more than the allowed amount, insurers generally do not pay more than the allowed amount, resulting in an out-of-pocket balance. The best way to handle this situation is to understand your policy and work with a dentist who understands your dental benefits.

How does my insurance provider come up with its allowed payments?

The allowed payments are often referred to as UCR payments (usual, customary, and reasonable). The amount for each treatment is negotiated between the insurance provider and the employer-based on several factors such as where you are located, the dental plan they pick, and the premium the employer is willing to pay to name a few.

Will there always be a balance for me to pay?

In most cases, negotiated allowed payments will only cover a certain amount of your treatment. Depending on the dental procedure, some have an annual maximum or a lifetime maximum. An annual maximum is the maximum benefit amount allowed for a specific procedure during the benefit year. A lifetime maximum is the amount your dental plan will contribute to the course of your lifetime. Lifetime maximums typically apply to certain services such as dental implants or orthodontic treatments.

If the cost of treatment is not covered in full, and there is an out-of-pocket dental expense, the patient will be responsible for the difference. In most cases, patients will still benefit from the  reduced balance after insurance is applied.

Why does my benefit plan require me to select a dentist from a list?

The dentists that appear on an insurance carriers list are dental providers who are in-network and have agreed to a contract with the benefit plan you are subscribed to. You are welcome to pick a dentist that is not on the list however, depending on your dental policy, you may or may not have out-of-network coverage. In some plans, out-of-network coverage means they cover all, a portion, or provide no benefits.

What is Direct Reimbursement?

Direct reimbursement is when the insurance company reimburses the patient for the amount spent on the dental care they received. A benefit of direct reimbursement is that it gives you the freedom to choose the dentist you want, regardless of whether the dentist is in-network or out of network. *This may vary as not all plans offer direct reimbursement.

Why does my plan only pay for the least expensive treatment?

Your local dentist may offer a variety of dental procedures to best treat your dental concerns. Each has different levels of effectiveness to address different issues and maintain the health of your teeth. However, some insurance companies allow for only a certain level of dental coverage for certain treatment plans to reduce the monthly premiums.

How do I get my dental treatment covered?

If you need significant dental care, your dental provider will typically provide you with a dental treatment plan. This document outlines what you need, what treatment will be done, how much it will cost, and how long it may take. Once you have a treatment plan, also known as a predetermination of benefits, we will provide you with an estimate of what is covered based on your dental policy and any out-of-pocket costs. That information will help you decide if you can financially proceed with the suggested treatment plan.

If the treatment is out of your budget, there are 2 options available. Your dentist may still work with you to create a plan that will fit your specific situation and still allow you to see great results. In situations like this, it is often done by breaking the treatment plan into stages that are spread out over time. For example, you would do the first stage of your treatment followed by your second stage of your treatment in the following calendar year, when your benefits will have renewed. Doing so will cover a greater portion of out-of-pocket expense as your insurance will cover the remaining portion when the benefits renew.

The 2nd option will be your dentist evaluating your condition and explaining all of your treatment options. In many cases, dental issues can be solved in more than one way. Depending on your insurance plan, some will only pay for the least expensive treatment, so we’ll recommend other affordable options if they’re available.

For example, let’s say you’re missing a tooth. The best permanent option to replace a missing tooth is with a dental implant with a crown. However, dental implant surgery costs more than other tooth replacement options and is not covered by your dental policy. An alternative to dental implants would be to use a dental crown. Crowns are far less permanent than implants; however it’s still an option to replace a missing tooth.

What Should I do if My Treatment Is Not Covered And I Think It Should Be?

Unfortunately, this is a decision that your insurance carrier and employer make. As the dentist, we have no power to make them pay. The best way to contest the claim is to address it with the insurance carrier.

Have questions about your dental insurance Plan?

If you have more questions about whether we are in-network with your dental insurance policy, or would like to know how to maximize your remaining dental coverage for the year, please contact our office (972) 468-1440 in Fairview, TX, and we’ll be happy to assist you.