What Does Dental Insurance Cover?

If you have dental benefits, are you aware of what’s in the fine print and which type of plan is best for you and your family?

Dental care has been a major topic for years. Many Americans are unaware that they have dental coverage, which is shocking considering 7 out of 10 people in the US actually do! The scope of this statistic becomes even more startling when you consider how many low wage workers don’t receive any benefits from their jobs other than food.

Many American’s take it as an entitlement to be given health insurance or dental coverage from their employer without realizing just what percentage-77%-of them already qualify and more importantly, need these services desperately; but surprisingly enough only 40% currently get such treatments through work programs because some employers still see dentistry as superfluous expense on top of salaries. Medicare doesn’t cover dental care, and most state Medicaid programs only cover dental care for children. 

To make the most of your dental benefits, you need to know these things:

Dental Insurance or Dental Benefits?

You may see the term dental benefits, which is different than insurance. An insurance plan is meant to absorb risk – like the risk you’ll need a root canal – and covers the costs accordingly.

A benefits plan covers some things in full, but other things only partially, while other things not at all. A dental benefits plan is meant to be helpful, but it’s not a catch-all. When you shop for dental coverage, make sure you truly understand what the plan covers.

Dental Plan Categories

The most common designs of dental plans can be grouped into the following categories, even though the features of the said plans might differ quite a bit.

  • Direct Reimbursement Programs – Direct reimbursement programs offer patients a reasonable way to get dental care. If you are looking for the right ways to save money on your next visit, this is it! The program pays out predetermined percentages of total amounts spent and doesn’t exclude coverage based on treatment type. You can go see any dentist in town and work with them towards healthy solutions that will give you a smile worth showing off!
  • “Usual, Customary, and Reasonable” (UCR) Programs – “Usual, customary and reasonable” (UCR) programs are known for allowing patients to go to the dentist of their choice. These plans usually pay a set percentage of the dental fee or an administrator’s “reasonable” or “customary” rate limit whichever is less. The limits come from agreements between purchasers and third-party providers which can be found in contracts.
  • Table or Schedule of Allowance Programs – Table or schedule of allowance programs determine a list of covered services with an assigned dollar amount. That amount represents how much the plan will pay for those services that are covered, regardless of what fee is charged by the dentist. The difference between allowed charge and the doctor’s fees can be billed to patients on top as additional costs after so many visits to cover it all in whole.
  • Capitation Programs – A capitation program pays a contracted dentist for their services per enrolled individual. In return, the dentists agree to provide specific types of treatments at no charge (with some exceptions). The premium paid may differ greatly from what is designated on paper as it relates to health benefits and insurance coverage; this type of payment provides an incentive for better care all around since higher-quality service means more revenue potential in comparison with other providers that do not offer free treatment.

Types of Dental Plans:

Similar to health insurance plans in many ways, dental plans are also very different than health insurance plans. You’ll generally have the following options:

  • Preferred Provider Organization (PPO): As with a health insurance PPO, these plans come with a list of dentists that accept the plan. You have the option of going out-of-network for cheaper dental care, but your costs will skyrocket if you do so.
  • Dental Health Maintenance Organization (DHMO): It’s like a health insurance HMO, but for dentists! You can find an in-network dentist with one of these plans that will provide you with set co-pays and/or no cost at all. However, if there is not an available out-of network provider close by or it requires more than the recommended treatment to maintain your dental well being then you may be forced to pay higher costs outside of this plan.
  • Discount or Referral Dental Plan: A new plan in the dental world is making waves because it will give you a discount on your care from dentists who participate. They are all partners and agree to provide discounts for their services if they know that there’s no insurance involved.

Understanding Dental Insurance Plans

Predetermination of Dental Costs

The dentist will state a diagnosis to the insurance company and submit how much they think it’ll cost them. The administrator then decides if you are eligible for any coverage, what services your plan covers, when you can get reimbursed (for example after only 3 treatments), and how much of an out-of-pocket expense there is before reaching maximum limitation on co-payments. The plans that require preauthorization for treatment will usually cover a certain amount of money before they need to be approved. This is also known as predetermination, precertification, pretreatment review process or prior authorization.

Annual Benefits Limitations for Dental

Your dental insurance plan may limit how often you can visit the dentist with a given procedure in an effort to minimize costs, but this is rarely necessary if you have been going for regular preventive care.

Your dental insurer will typically only recommend limitations on visits and treatments when it has reason to believe that your current benefits are being abused or exceeded by too many services within one year. But, as long as we stick with our yearly routines of check-ups and cleanings between procedures like fillings, root canal therapy, teeth whitening sessions etc., there shouldn’t be much worry about meeting these limits!

Peer Review for Dispute Resolution in Dentistry

In order to protect patient’s rights and minimize costly court cases, most dental insurance companies have a peer review mechanism. The goal of this is fairness within the medical field as well as individual case consideration with thorough examination of records, treatment procedures, and results. Most disputes can be resolved satisfactorily for all parties involved!

Many dental plans offer a peer-review process that eliminates many expensive court cases while ensuring fair play between dentists and patients in any dispute or disagreement over treatments given by the dentist during an appointment. Peer-review aims at fairness among all members present including individual case considerations – meaning each issue will be thoroughly examined through mechanisms such as looking at their respective treatment procedure records before coming up with questions pertaining to how they should move forward.

Understand What Dental Plans Cover

Dental policies generally cover some portion of the cost for preventive care, fillings, crowns, root canals and oral surgery such as tooth extractions. They might also provide coverage to orthodontics or prosthodontics procedures including dentures and bridges. Generally you are covered twice per year with a dental policy for these services although it will depend on your specific plan which is typically dictated by deductible costs associated with each service rather than an unlimited number of visits allowed in any given calendar year period.

If you get an individual policy, some procedures may not be available in the first year of coverage. For example, orthodontics often requires a rider for any kind of policy and periodontics and prosthodontics are only covered if they’re considered medically necessary by your dentist or doctor.

If you have dental insurance through an employer-sponsored plan with benefits specific to this option (such as the type described above), it’s important that before committing yourself to one provider over another all other factors should also be taken into consideration like what doctors will participate under their network?

Most dental plans follow a 100-80-50 coverage structure, which means they cover preventive care at 100%, basic procedures at 80%, and major procedures 50% of the time. But there are some that offer different packages with varying benefits depending on your needs.

A common misconception about most Dental Plans is their strict adherence to only covering an array of services under 30%. That’s not true! Some insurance companies will allow people to take out additional policies for specific treatments such as fillings or crowns; however these usually come with higher premiums in order compensate for the costlier procedure(s).

Limitations of Dental Insurance Plans

Many dental PPOs cap annual benefits at $1,500. This covers the majority of routine procedures and services that you will need during a year under your plan. The drawback is if something major happens like root canal or oral surgery costing more than $1500 in one visit, then it would be up to you to pay for any expenses exceeding this limit each month until the end of your coverage period before receiving reimbursement from insurance company (which could take months).

There’s generally a separate lifetime maximum for costs regarding orthodontic procedures.

Some plans may totally exclude some services or restrict them to be performed at a lower cost, sometimes which is not possible for the dentist (as it’s not profitable). Therefore, you should know specifically what services the plan covers and excludes.

Most dental insurance plans have limitations and exclusions that are designed to keep the costs of dentistry from going up without penalizing patients. For instance, all plans exclude experimental procedures or services not performed by a dentist, but there may be some less obvious exclusions as well. Sometimes, medical health insurance overlaps with dental coverage. For example, exclusions in your dental coverage plan may be covered by your medical insurance plan. You must read and understand the conditions of your dental insurance plan for this matter. 

What to Do Before a Dental Procedure

Read your dental policy closely to determine if your procedure is covered. Call your insurance company if you have any questions you need answered. Should you need a major procedure, speak to your dentist about submitting an estimate for the cost. This will help prepare you of what is likely owed after coinsurance and deductibles have been met by any amount that was left over from paying out-of-pocket before coverage begins or when it expires at some point during policy year.

It’s also important to understand how emergency care can be handled on your dental plan as many offer provisions if urgent issues arise where there may still be copays required with higher percentages rather than just flat fees like those found in routine visits unless they’re covered under specific plans which are often more expensive but provide better coverage options for emergencies such as this one.

What to Consider About Dental Insurance

If you have dental coverage through your employer, it’s an easy choice. Often times, this is cheaper than getting a separate policy on your own. If you don’t and are looking for one yourself, talk to the dentist of yours; they might be able to recommend based off what plans would work best for someone with such history as theirs!

As you compare dental benefits plans and dental insurance plans, try to find out the following things:

  • Whether your dentist is in-network
  • Total costs for the plan each year, including co-pays, premiums, and deductibles
  • Annual maximum
  • Limitations on pre-existing conditions
  • If there is any out-of-pocket limit
  • Coverage for braces, if needed
  • Emergency treatment coverage
  • Can you choose your own dentist
  • Who controls treatment decisions: the dental plan or you & the doctor
  • Whether the plan covers diagnostic, preventive and emergency services, and to what extent
  • What yearly routine treatment is covered
  • What major dental care is covered
  • Can you schedule an appointment at the dental clinic whenever you like
  • Who is eligible for coverage under the plan (family, spouse, etc)
  • When coverage goes into effect

Your dentist can’t answer specific questions about your dental insurance plan or predict what level of coverage for a particular procedure will be. It all depends on the contracts negotiated, but you’re better off contacting either your employer’s benefits department if they offer one that puts them in charge or your primary insurer to find out how much it’ll cost and whether there are any pre-existing condition limits because every company is different when it comes to their policies.

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