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, knowing how to use it best can be tricky. 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.
Dental insurance is a type of insurance that helps you pay for the dental treatment you need. All types of dental plans are different, but in most cases, it covers preventive care like regular checkups, X-rays and cleanings. Your plan may also cover dental treatment like fillings, extractions, root canals, and crowns, depending on your dental coverage. The dental plan you pick will make a difference in the dental 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 knowing which dentist you can see and to know how to get the most out of your dental benefits. If you don’t understand your dental plan, it’s easy to miss out on services or pay more than you should. This may vary for some patients, but most insurance policies generally 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.
If your dental plan is considered 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.
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 fewer limitations than DHMO, DMO, or HMO. If you have a dental PPO plan, your dental insurance provider has a list of dentists who take your plan and 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 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 cost-conscious people, and the plan is designed where you select from a list of primary care dentists. 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.
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. In addition to verifying that you are in-network, the dental office will get an estimate of any out-of-pocket expenses for your dental needs. Depending on your plan, most plans use a benefit year to determine when the benefits are available to use.
After you visit your dentist, they 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 obligations are based on the dental treatment you receive and the specific details of your treatment plan.
Deductibles – A deductible is an amount you must pay prior to your benefits.
Coinsurance – Once your dental 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 coinsurance. The main difference is that coinsurance is a set percentage in most cases, 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 dental 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 dental coverage is in place before any dental treatment can start. 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 specific 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 treatments on certain teeth.
Pre-existing conditions – An illness or injury you have before starting a new dental care plan may be considered a pre-existing condition. If your plan has a pre-existing condition clause, your dental coverage will not cover the treatment required, meaning you will be responsible for paying for the treatment needed.
There are 4 types of procedures that are covered in your insurance plan.
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.
Depending on your dental plan, some plans offer an Alternate Benefit Clause that stipulates that specific dental procedures must convert to a less expensive procedure. Patients can still request the more expensive treatment, but they will only be reimbursed for the approved less expensive treatment option if it serves the same function, and they will need to pay the difference out of pocket.
Sloan Creek Dental is in network with most PPO dental insurance providers, but if you don’t see your provider on this list, please call our dental office for more details. Some of the insurance providers we’re in network include:
Aetna, Ameritas, Anthem, Careington, Cigna, Delta Dental, Dental Network of America, Guardian, Humana, Metlife, Principal, Sunlife, United Healthcare, Zelis
Your oral health is important and if you have dental insurance coverage, don’t throw away your money by not using it. 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.