The New Year is upon us and with it, a fresh start. For many of us, this means new dental insurance coverage. While you may believe that having and using dental insurance matters, it might be hard to know how to use it best. Dental deductibles, maximums, coverage levels – they can be confusing! It all may leave you scratching your head and asking the question, “How does dental insurance really work?” Not to worry! As your local dentist near Allen & Fairview, we’re here to help you understand the basics of dental insurance and help you get the most out of your dental benefits.
What is Dental Insurance?
Dental insurance is a type of insurance that helps you pay for the dental treatment you need. All types of plans are different, but in most cases, it covers preventive care like regular checkups, X-rays and cleanings. Depending on your dental coverage, your plan may also cover dental treatment like fillings, extractions, root canals and crowns.
There are many insurance plans out there, and each one is different in terms of how much you will be expected to pay for certain treatments, and what your coverage will look like. The dental plan you pick will make a difference in the care you receive, which dentist will be in-network, and how much you spend on monthly premiums.
Like any insurance, understanding your dental policy is the key to know which dentist you can see, you can get the most out of your dental benefits. If you don’t understand your plan, it’s easy to miss out on services or pay more than you should. This may vary for some patients, but in general, most insurance policy follow the 100-80-50 payment structure. Where the insurance will pay for 100% for preventive care, 80% for basic procedures, and 50% for major procedures.
What is the difference with in-network and out-of-network?
If a dental provider is considered to be an in-network dental provider, the provider has agreed to follow your insurance plan’s approved fee schedule and payment policy.
For example: If a provider charges $150 for a procedure and the insurance carrier approved amount is $75. By being in-network with this provider, you would save $75.
If a provider is considered out-of-network with your insurance plan and you have out-of-network benefits, you will be responsible for the difference between the providers full fee and what your insurance plan will pay for.
For example: If a provider charges $150 for a procedure and the insurance carrier approved amount is $75. By being out-of-network with this provider, you would be responsible for the remaining $75.
2 types of dental insurance
There are 2 types of dental insurance that most plans fall into.
Preferred Provider Organization (PPO) – In most cases, PPO plans offer better service and have less limitations than DHMO, DMO, or HMO. If you have a dental PPO plan, your dental insurance provider has a list of dentists who takes your plan and is known as the provider network. Visiting an in-network doctor (a dentist on that list) will give you the greatest savings as your coverage will cover 100% of the cost for preventative care. Typically you can see a dentist who is out of network (not on the list) but you’ll pay more out of pocket. Note that just because you may have a dental PPO plan, it doesn’t necessarily mean they are in-network with your insurance company. The dental office will verify and let you know whether you are in-network or out of network.
Dental Health Maintenance Organization (DHMO, DMO, HMO) – In general, DHMO, DMO, HMO plans are designed to keep your dental costs lower in monthly premiums and out-of-pocket expenses. They are best for people who are cost conscious, and the plan is designed where you select from a list of primary care dentist. One of the main drawbacks with these types of insurance plans is that you’re limited in who you can pick from, and have strict restrictions on insured members.
How Does Dental Insurance Work?
Once you find your local dentist that you want to go to, your dental office will typically verify your dental insurance to see if they are in-network with your insurance plan, and get an estimate of any out-of-pocket expenses for the treatment that you need. Depending on your plan, most plans use a benefit year to determine when the benefits are available to use.
After your visit with your dentist, we will send your information to your insurance company. They will review and process the claim, and explain how the claim is paid with an EOB, or explanation of benefits. Some of your financial obligation is based on the dental treatment you receive, and the specific details of your dental plan which may include.
Deductibles – A deductible is the amount you must pay prior your benefits kick in.
Coinsurance – Once your deductible is met you will pay a percentage of the cost of covered treatment, and the insurance company will pay the remaining percentage. This percentage will vary by plan and is in your dental benefits document.
Co-pay – A set out-of-pocket cost you are required to pay before receiving dental treatment covered by your insurance provider. A co-pay is similar to a coinsurance. The main difference is that in most cases, coinsurance is a set percentage, and co-pay is a set dollar amount.
Annual Maximum – The limit set by your plan that states the maximum dollar amount that will be paid for covered services during a given benefit period. Once you reach your out-of-pocket maximum, you pay all future expenses in excess of the amounts stated in your plan’s fee schedule.
Preauthorization – Some plans have pre-authorization requirements to ensure proper coverage is in place prior to any dental care from starting. The dental office will contact the insurance company on your behalf to ensure you get the preauthorization needed.
Exclusions – A list of dental services that the insurance plan will not cover.
Waiting period – The waiting period is the length of time you must wait before you are eligible to receive certain treatments. The plan will not cover certain dental procedures being performed during this time.
Limits – Some dental plans have limits on the frequency of procedures that can be done within a benefit period. For example, in most cases, your plan will cover two cleanings per year. You may need to wait six months between cleanings, and limits may apply to the frequency of x-rays and to treatments on certain teeth.
Pre-existing conditions – An illness or injury that you have before you start a new dental care plan may be considered a pre-existing condition. If your plan has a pre-existing condition clause to it, your dental coverage will not cover the treatment required, meaning you will be responsible for paying for the treatment needed.
Typical dental insurance coverage
There are 4 types of procedures that are covered in your insurance plan.
- Diagnostic and preventative procedures – These types of procedures are generally covered 100% and include cleanings, exams, x-rays, and fluoride treatment. You should receive two cleanings and two exams during each annual benefit period.
- Basic Procedures – Procedures that fall into this category are usually covered at 80% and include fillings, simple extractions, 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 services.
- Major Procedures – Major procedures are covered at 50% and include crowns, bridges, dentures, and complicated treatments. Just like basic procedures, there may also be a waiting period, frequency limit, and or deductibles for certain types of services.
- Orthodontic treatment: Coverage on orthodontic treatment varies between all plans. Treatments that falls into this category includes traditional braces, clear braces, aligners, and other devices used to align your teeth.
What is Direct Reimbursement
A direct reimbursement is when the insurance company reimburses the patient for the amount that was 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.
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 insurance coverage for the year, please contact our office (972) 468-1440 in Fairview, TX, and we’ll be happy to assist you.