Dental insurance: you pay for it every month, and it’s supposed to cover all of the procedures that your dentist performs…right? Yes and no, but not exactly. Every plan varies from one person to another, but in general, this is what you need to know when it comes to the specifics of how your plan should work:
First: Your Employer (or You) Purchase a Dental Insurance Plan
Unless you’ve purchased your own private dental insurance, your plan was arranged and purchased through your employer. Either a small business owner or human resources department bought into the plan, based on what they could afford and what they felt was fair coverage for their employees.
The specifics regarding what your insurance covers, maximum allowables, deductibles, and all those types of things are decided by your employer and the human resources department. It has nothing to do with the insurance company or your dentist. Many times, people get angry with their dentist, when the problem originates with the type of plan their employer purchased.
Second: The Relationship Between the Plan and Your Dentist
Based on the type of plan your employer has bought into, you may be restricted as to which dentist you can see. Some plans will only pay for treatment if you see a dentist in their network, while others are more flexible.
Certain dentists may decide to participate in particular networks based on where they work and how much the insurance company reimburses them for procedures. To be a “preferred provider,” it means your dentist must offer services at a discounted rate agreed upon by the insurance company. It’s sort of the insurance company’s way of saying “We’ll refer patients to your office, if you agree to only charge what we tell you that you can.”
If you’re seeing an out of network dentist, your insurance (depending on the type of plan) may still cover your treatment, but the percentage of coverage is lower, and you’ll be left with a bill for the unpaid balance.
Third: Levels and Types of Benefits Allowed
Let’s assume that your dentist is in network and you need to schedule a checkup. When you’re there, you also find out that one tooth needs a filling and another tooth needs a crown. To you, this might all seem like everyday dentistry. To your insurance company, you’ve just hit three tiers of coverage categories.
- Preventive: Checkups, exams, cleanings, sealants, x-rays, and fluoride are all “preventive” in nature. That is, they help your dentist screen for — and avoid — issues before they have a chance to evolve into something worse. Fortunately, most insurance plans cover preventive services at 100%, within specific guidelines.
- Restorative: Fillings are entry-level restorations used to repair areas where tooth decay hasn’t been prevented. Fortunately, it does mean that you caught it before the problem got too much worse. The typical insurance plan will cover restorative treatments at 80% and pass the other 20% onto your personal dental bill. It’s sort of their way of saying, “let’s not let this happen again!”
- Major: A crown or root canal may seem “routine,” but to your insurance company it’s regarded as major work. On average, most policies cover major work somewhere around 50% and the other 50% is the responsibility of the patient (you.) Sure, there are times when major work can’t ever be avoided, but if you use your policy benefits to their optimal level, your preventive services would have ideally helped you to avoid this kind of treatment.
Fourth: Annual Deductibles and Maximums
Since the 1970s, most maximum allowable benefits for dental insurance have remained about the same. Yes, even with inflation!
Back then your policy might have covered everything major or restorative that was needed, but now it might only cover one crown and a root canal, if that. But first you have to hit your deductible for the year before the benefits start to pay and even then you have to plan on the benefits maxing out. What you’re left with is the need to plan ahead and make a smart budget when it comes to planning major dental work.
Fifth: Resetting Your Insurance Each Year
You want to take care of your dental work as quickly as possible, before infections get any worse. Most people’s benefits “roll over” at the end of the year, which means more people try to get as much work done around the holidays as possible, then save the rest for the next year (when a deductible has to be met again, but your benefit maximum resets.) Plan accordingly! It’s often challenging to get an appointment during this time of the year, for this very reason.
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