Understanding Your Dental Insurance Coverage

Understanding Your Dental Insurance Coverage


If you’ve ever found yourself getting frustrated with your dentist’s office, it might have had something to do with the type of coverage you have through your dental insurance. You might tell yourself “I have dental insurance to cover all of this! Why should I have to pay so much for treatment?”

To clear up any unnecessary arguments (or unwanted expenses) at the dental office, you can take a few proactive steps to know exactly what your insurance covers and for how much. Here’s what you need to know:

Prevention Comes First

By nature, all dental insurance plans are designed to be prevention focused. That means you’re going in every six months for your checkups and cleanings, allowing your dentist to spot problems before they become major issues down the road. As such, your preventive appointments usually require little, if any, money out of pocket.

Oral hygiene, periodontal screening, and nutritional counseling are often overlooked by patients regarding their importance…but it can pay off to take your dentist’s or hygienist’s advice! Your insurance company’s secret is that if you don’t keep that advice, you’re going to pay more for your appointment.

Out of Network vs. In Network

To be in network with your insurance company, a dentist has to agree to take specific cuts in how much your plan reimburses them for certain treatments. It’s the insurance company’s way of helping the dentist increase how many patients come to them for services.

Sometimes, those cuts are too low for a dentist to want to be a participating provider, but that doesn’t mean that your insurance still can’t be processed by them. It just means if you go to an out of network dentist that you’ll receive lower reimbursement by your insurance company (leaving you with a balance that you’ll be responsible for paying.)

If you have an HMO plan, you won’t be able to use your insurance at an out of network dentist office, period.

Fee Schedules

A fee schedule is what your dental insurance carrier deems is an appropriate amount that’s allowed to be charged, based on where you live or the type of insurance you carry. It can be based off of any dental providers in your area, and it’s up to the decision of your insurance company to set the amounts.

Why is this important? Because if your insurance will only pay $25 for a sealant, but your dentist charges $35, even though it’s preventive treatment that is covered at “100%” you can still get a bill for $10 when it’s completed. It’s a frustrating thing to both insured patients as well as the dentist, because it can cause a lot of misunderstanding when it comes to explaining who is responsible for what.

Basic vs. Major Dental Treatment

Once you get past the point of preventive procedures, you come to a range of treatments that are covered at different levels…such as 80%, 50%, and so on. Basically, the more involved your treatment becomes, the less your insurance company will pay for it. It’s sort of their way of saying, “You need to prevent problems and take care of them earlier.” For instance, a filling will have a higher level of reimbursement than a crown or a root canal.

Fillings are “basic” and covered at a higher percentage of reimbursement, where “major” crowns or root canals are at a much lower rate of coverage. The dilemma here is that you really need the dental work done, but your insurance won’t cover more than about half of it, if that. So you’re left with the decision of paying out of pocket or just avoiding the treatment altogether because you can’t afford it.

Waiting Periods and Preapprovals

So you’ve settled on getting that crown after all (because otherwise, you would need an extraction, dental implant, and another crown after all of that.) If your insurance has a waiting period, you might have to wait up to 6 months before you can get your crown treatment scheduled, otherwise they’ll reject paying for any portion of it. The problem with that is your tooth could break down by then and still need to be extracted.

Depending on the type of policy that you hold, your insurance may say you need to wait 3 to 6 months for treatment or have them “pre-approve” it before you’re able to schedule the appointment. About a month later, they come back and tell your dentist how much they might potentially pay on your crown, but the preapproval itself isn’t even a guarantee that it’s covered. We know, it doesn’t make a lot of sense, but that’s how most dental insurance plans work.

Avoiding the Dental Insurance Dilemma

While some people have perfectly great dental insurance and healthy teeth, you might not. There comes a point where you need to decide to shop around for other dental insurance plans or even a discount plan to see if one will save you more money. If you’re considering a discount dental plan, contact one of our savings specialists for a no-hassle quote!

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