Over the years in my dental practice, I have found there is significant confusion about what dental treatment is covered by dental insurance and why some services are denied. This is a very confusing subject so and there is a wide variety of types of Dental Insurance plans available, however, it seems I can lend some clarity to this subject. I will try and cover some of the basic points about what you need to know about your dental insurance before you sign-up for a plan or decide on a treatment plan.
What exactly is a Dental Insurance?
It is an insurance coverage for individuals to protect them against dental costs. Dental insurance is an arrangement by which a company undertakes a guarantee of compensation for specified loss, damage (dental cavities), or dental disease in return for payment of a specified premium. It insures against the expense of treatment and care of dental disease and accident to the teeth. Basically, it is designed to pay a portion of the dental care costs.
Regular dental and oral health care helps to maintain the health of your teeth and gums, therefore, most insurance will reimburse cleanings and maintenance at a high level. The lack of regular dental care can lead to major problems including expensive treatments. According to the journal of American Dental Association, spending on preventive dental procedures such as dental cleaning resulted in the reduction in overall medical costs. Most dental insurance plans do not cover restorative treatments at the same level as preventive care which is unfortunate as it is more expensive.
Though very similar to health insurance, dental insurance coverage generally isn’t included in the health insurance benefits packages. You need a separate individual dental insurance which is basically preventive in design.
Insurance companies are the REAL designers
As each important document comes with a terms and conditions clause, so does the dental insurance coverage. Insurance companies have designed many different packages and varying options of coverage for you to choose from. Find out what is and what not are included in the dental insurance package. There are insurance specialists in most dental offices that can help (ask Tami or Brenda in my office). Read the documents clearly, carefully before you sign the contractual relationship between you, your employer and the insurer which in reality doesn’t the dentist who can only provide the pre-treatment estimate. A pre-treatment estimate gives you in advance what procedures are covered, the amount the benefit plan will pay and your financial responsibility. This estimate is not a guarantee of payment because when the services are complete and a claim is received from you for payment, the insurance company will calculate the payment based on your current eligibility, amount remaining in your annual maximum and any deductible requirements. However, clichéd this statement may seem, the final cost and coverage is determined by your insurer.
How to choose the right one?
While choosing the dental insurance plan which is right for your needs, you would have to weigh in these factors: the number of people who need the insurance cover for, the exact amount to be allocated on a monthly or yearly basis, to what extent the coverage is required. More importantly, gauge the propensity of any dental treatment and choose accordingly. Unless you ask what exactly is being covered, you may not know what type of plan you are purchasing (PPO or DMHO or a Discount Plan). Now, these are the points you need to consider: the exclusions, limitations, co-payments and lifetime benefits.
Things to keep in mind
You need to remember: MDCIR – Maximums; Deductibles; Co-Insurance; Reimbursements. Dental plans have a maximum (annually). This “maximum” is the maximum amount a dental plan will have to pay towards your dental costs within a specific benefit period (Jan-Dec generally). Any costs above this annual maximum have to be paid by you. Always check your plan booklet/kit for its specific details but dental plans now vary from $1000-$3000/year.
While deductibles are those which vary according to the plan you have taken. First of all, as soon as you take the dental insurance plan or before/after a dental treatment/checkup– check the deductibles which aren’t covered in your dental insurance coverage and proceed accordingly. During the benefit period, you would have to personally pay a portion of your dental bill before the benefit plan contributes to cover your applicable/permissible dental costs in accordance with your plan. And coming to the term “coinsurance”, many dental insurance plans have a coinsurance provision which means that the benefit plan pays you a predetermined percentage of the cost of your treatment and the rest by you. So whatever you would pay is called coinsurance and its part of your out-of-pocket costs. In general, it’s paid even after a deductible is reached.
Talking about (classes of) reimbursements levels, we need to address the *terms and conditions clause and that varies according to the plan, the “network” (in-network insurances or out-of-network insurances), the services offered (cosmetic and restorative services).
Hopefully, this has helped to explain some of the terms and relationships surrounding your dental insurance plans. Again, there are specialist in my office that help patients with this everyday.
To know more about the things to consider before selecting or changing your dental plan, any other trivia about dental insurance plans, or dental care in general, contact Dr. Mark Grace or Dr. Tracy Adams at 206-623-5546 or at email@example.com.