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You may not realize it, but dental insurance is completely different than medical insurance. Because people use their medical insurance more, they may get confused about the differences. We meet with so many patients who are not in touch with what their dental plan actually covers, so we wanted to share some important information and tips to keep you informed about your coverage and its use. Please note that the information we’re providing does not apply to HMO/DMO plans.
With most medical insurance plans there is no real maximum spend. You may have to pay $4,000 out of pocket to get your deductible met before insurance starts paying, but there most likely will not be a cap on the coverage for the year.
However in dentistry, while the deductibles may be smaller at $50-$100, the maximums are much lower. For care that goes beyond the routine, most plans cap coverage at $1,500 a year, although higher annual limits can be arranged by paying a higher premium.
Because dental insurance coverage differs so greatly from medical insurance, it is more appropriate to call it a “dental benefit”. Dental insurance acts as more of a gift card to put towards your treatments. Once the dollar amount is reached, the “gift card” has run out.
Most dental policies emphasize prevention and diagnostics, typically covering two annual exams and cleanings, plus X-rays. But the real benefit is being covered for bigger-ticket procedures, such as fillings, root canals and crowns. However with a limit of only $1000-$1500 per year, this limit could be spent on one larger treatment, such as a root canal.
People with dental insurance commonly have what’s described as “100-80-50” coverage, meaning it pays 100 percent of the cost of routine preventive and diagnostic care, such as checkups and cleanings; covers 80 percent for fillings, root canals and other basic procedures; and 50 percent for crowns, bridges and major procedures. Although you have this coverage, once you have any procedure (including a cleaning) it starts deducting from the $1500 maximum.
So if treatments are needed, the low maximums of dental insurance could be quickly reached in one year. But you can’t just treat one tooth a year, otherwise you’re going to end up spending more money when you delay treatment. For instance handling a filling when it is small is a much lower expense than letting it go untreated. When treatment is delayed, the decay can spread and you may need a root canal and a crown, at a much higher expense. So going to the dentist every 6 months and catching dental issues while they’re small is really important, whether or not you have insurance or a dental benefit.
Here are 4 tips to help you understand your dental insurance:
1. “Out of Network” does not mean “Out of Coverage”
With medical insurance, especially in North Carolina, you have to pick a system (ex: Novant or CMC) and sometimes you will get coverage at one and not the other. So sometimes in the medical world, out of network does mean “out of coverage”. Receiving medical treatment by an out of network provider could mean that none of the treatment is covered by insurance.
However with dental insurance and PPO plans, there may be no, to very little, difference between what your insurance company will cover for dental providers in and out of network. “Out of network” for a dental provider may just mean that the percentage of treatment the insurance company covers reduces, but coverage is still available.
2. Pick Your Provider
You don’t want the insurance to dictate the provider you choose. You as the patient should choose your dental provider, because that’s the definition of PPO – you get to pick your provider! If there is a difference in coverage between providers, you have to ask yourself “Is the difference enough to possibly sacrifice quality of care?” (Remember, you may get what you pay for.)
3. Know Your Plan
Each dental insurance plan is particular to that individual. Just like homeowner’s insurance, the plan that covers your house is very different from your neighbor’s plan. If you understand your plan and coverage, it gives you the power and freedom to seek the care that is right for you.
It is also important to note that insurance companies pay a percentage based on the insurance company’s “set allowable amount”– these are price levels the insurance company has set for each treatment. They are also referred to as “UCR” rate, the usual, customary and reasonable rate for certain treatment. It is important for you as a patient to know the allowable amount, and your responsibility for the balance.
4. The Insurance Company Likes You Better
An insurance company will reimburse you, as the patient, faster than it will reimburse the dental practice. YOU are their customer, after all, NOT the practice. So if you are in a situation where you have to pay the provider in full, the insurance company will reimburse you directly. Now with electronic submissions, the reimbursement can happen within 2-4 weeks.
Even though we recommend you verify your own benefits, a reputable practice will help you figure this out. We will submit your insurance paperwork, and give you an instruction sheet on the next steps to submit or receive reimbursement. Our practice guides the patient through the insurance process until the reimbursement happens, and we are happy to help you with any claim issues along the way.
If you’ve been told you need a root canal, contact us for an evaluation, as early as possible. Our office will break down that coverage for you so you can get an idea of what you have to use toward treatment.
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