USE it or LOSE it…
The scoop on dental insurance
Written by Betsy Cord
It’s October already?!? I guess it’s true that the older you get, the faster time flies. Seeing as how we only have about 10 weeks left in the year, it seems like the perfect time to talk about insurance benefits. Dental insurance can be a very confusing topic for nearly everyone, especially with recent law changes. So, I’m going to give you a general breakdown of the knowledge I have picked up over the last 17 years in dentistry.
Dental insurance is NOT like medical insurance! It’s too bad that medical, dental, and vision policies aren’t combined into one comprehensive plan more often-that would help clear up a lot of confusion. In fact, most employers purchase options for their employees through totally different companies. Just because your medical is with Cigna, or Blue Cross doesn’t mean that your dental policy will be also. When you receive your initial packet of benefit information from your employer, take note of which company each policy is through. Even if you don’t receive an insurance card, the company name along with your personal information is sometimes enough to gain access to your benefits. I am always happy to do a little research, if it saves you some trouble.
MAXIMUMS- There is a yearly maximum benefit that a policy will pay out for each individual covered. This is most often between $1200-1500, but I’ve seen it as low as $500 and as high as $5000-10,000. After a policy has paid up to the maximum dollar amount, it WILL NOT pay any more until the next benefit year (usually Jan. 1-Dec. 31, but can vary.) This seems crazy, right? It’s the opposite of a medical policy where you have a limit to your out-of-pocket copay, and insurance picks up the remainder. Sometimes, I come across policies that will cover check-up and cleaning visits outside of the yearly maximum, but I see that only about 5% of the time. So, here is a key point when purchasing a policy- If your premiums throughout the year add up to more than the maximum payout per year, you are wasting your money!
As we near the end of the benefit year for most people, it’s wise to evaluate the amount of benefits you have remaining, and use them up for any necessary treatment. If you don’t, they will disappear! Take advantage of what you have remaining so there is some wiggle room with next year’s benefits-you never know when you’ll have an emergency.
DEDUCTIBLE- Deductibles in dental insurance are almost always waived on preventive treatment (exams/x-rays/cleanings.) That means you don’t have to pay it unless you’re having some kind of treatment completed. The deductible is almost always $50 each year for individuals, but can be $25-100 with some plans. There will also be a family deductible-often double the individual deductible. In a family situation, if two members of the family have paid a deductible for the year, then you won’t have to pay another one when a third member has treatment to complete. Avoid policies that don’t waive deductibles on preventive treatment, if possible. Otherwise, they may as well just add it on to your premiums each year.
WAITING PERIODS- These are too often a surprise after treatment is completed! Waiting periods are the insurance company’s way of ensuring that they don’t pay for any “pre-existing conditions.” They can be found in lengths of 6 months to two years, and are usually restrictive of major and sometimes restorative treatments. In a policy with a waiting period, you will not have any benefits for the specified treatment until the waiting period is over. Many times this is in the very fine print, usually not disclosed to me when I pull up a breakdown of benefits, so be careful of these!
The missing tooth clause is a similar form of declining benefits for pre-existing conditions. A common inclusion, this rule limits replacement of teeth that were lost or removed before the policy began. So, if you had a tooth extracted before the effective date of your policy, and decided to replace it with an implant after the fact-it would not be covered.
BENEFITS- Really awesome policies will pay 100% for any service that you have completed, up to your maximum. However, most often there are smaller percentages for different “types” or “tiers” of treatment. An average policy will cover 100% of preventive treatment (cleanings, exams, and sometimes radiographs), 80% of restorative treatment (periodontal cleanings and scaling, silver or tooth colored fillings, and root canals), and 50% of major treatment (crowns, bridges, dentures.) Once again, the amounts can vary greatly depending on the policy and whether or not you have different benefits for in-network or out-of network dentists. If you’re offered a policy with this 100/80/50 breakdown, it is most likely a decent one.
That brings us to a subject that I get a lot of questions about…
IN-NETWORK PARTICIPATION- Finding an excellent provider within your network is a difficult task. It doesn’t always happen. This is because providers are usually asked to accept a smaller fee for treatment on patients within the network. For many insurance companies, the fee difference is tremendous, and wouldn’t allow a provider enough room to ensure quality care. I can’t speak for anyone else, but as a patient, I don’t want to receive a lower standard of treatment because my doctor has to write off a large percentage of the procedure. I don’t want to cut corners on anything when it comes to my health. Consequently, many providers elect not to join networks that would require them to do this.
Many of the policies we file with allow fees that are considerably higher than ours, but there are also many on the other end of the spectrum. Here’s where it gets super confusing-a single company can have several different fee schedules that are used for different plans. Obviously, in this case a policy with a lower premium would have a lower fee schedule.
When choosing your provider, be assured that you don’t always have to stay within your network. PPO (Preferred Provider Organization) policies are designed to give you a choice as to whom you would like to see. There are a few things to look out for, though. Review your benefits carefully: do the benefit percentages decrease if you see a doctor out-of-network? Does the maximum yearly benefit change? Always read the fine print. Sometimes, it’s worth paying a little more to see someone out of network if you’re going to receive higher quality treatment. Either way, I would rather you understand your benefits in advance. So, if you have questions regarding any part of your policy, let me know and I will look it over for you.