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What does my dental insurance cover?

The patient is always responsible for the balance

Many patients with dental insurance feel they are well covered when they visit the dentist. They are quite surprised when they find out they have to pay more than expected or for the entire treatment even with their insurance coverage. Most patients are well informed through their company on the basics covered, cleanings, x-rays, fillings, etc. Since it is ultimately the patient's responsibility to pay the final balance, it's a good idea to know the underlying details behind insurance coverage in most cases.

Dental Insurance Highlights

  • Yearly Maximum - This the total amount your insurance company will issue in checks to your provider during a 12 month period, if you have a $1500 maximum it doesn't mean you can go out and get two treatments for $750 each. Your insurance covers a percentage of each treatment, they will continue to pay on approved treatments until they reach the maximum within the time allowed. The benefit year doesn't always run from December to January, you should be aware of when your coverage year ends in order to coordinate your treatments in a timely manner and not loose any of your yearly benefits. Remember, if you don't use your maximum, you loose it. Some plans allow a seperate maximum for orthodontic treatments.
  • Deductible - This is a yearly fee paid by you and must be met before your insurance starts paying your treatment claims. This is generally collected by the dental office during your visit. Understand what your individual and family deductible is. If you're a family of 3 and your family deductible is $150, each family member will pay $50, until the $150 is met. Most plans do not require you to pay this deductible

    during your initial diagnostic and preventative visit (routine cleaning, x-rays, exams), but when you have an actual treatment performed.

  • Frequency limitations - This is the number of times you can have a certain procedure performed during your coverage year. Many plans allow 2 cleanings a year. You must really understand whether you can have 2 cleanings "anytime" during the year or exactly 6 months apart. If for any reason you were to go to a dentist and in less than 6 months go to a different dentist and have a cleaning done. You will get that surprise statement in the mail to pay for a visit.
  • Co-Pay - This is a comfusing subject for most patients, they often comfuse co-pay with deductible. Co-Pay is the percentage of the treatment you share in paying with your dental plan, if something costs $100 and your plan covers 80%, you pay $20 and they pay $80. It is essential that you find a dental office that not only accepts but is contracted with your insurance company. A contracted dentist agrees to accept the plan's discounted fee schedule which translates to savings for you. By visiting a contracted dentist, your yearly maximum covers more treatments. A non-contracted dentist usually gets paid based on his usual and customary fees (UCR).В 

Even if you have a full understanding of the items above, sometimes you are faced with additional financial responsibility, let's take a look at some other situations that tend to occur regarding certain treatments:

I can't say your plan will have all these limitations, but I can almost guarantee it will have one or more of these. A well informed patient, is empowered to make the right decisions. Here's a quick matrix to help you quickly view everything mentioned:

Category: Insurance

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