Dental Insurance Basics
The best way to take full advantage of your dental insurance coverage is to read your plan information carefully and understand its features. Do not rely upon estimates given at the dental office – your financial responsibility may often exceed their best guess, which is based upon broad
general guidelines provided by your plan. Contact your HR or your insurance company with specific coverage or benefit questions before each visit. This is your responsibility as an insurance product consumer, and has nothing to do with your health or the medical necessity of treatment.
Most insurance companies offer benefit plans with different features. Your employer chooses the coverage level available to you. Your dentist may or may not “participate” in the PPO network for your dental plan. If your dentist does, he or she will submit your claim. If not, you may be responsible for paying your dentist and submitting a claim to the insurance carrier.
Dental benefits are calculated within a benefit period, which is typically one year –
but not always a calendar year. Be aware of your benefits and when you are approaching deductible payments or plan maximums.
- Reimbursement Levels
- Pre-treatment Estimates
- Limitations and Exclusions
Most dental plans have an annual dollar maximum. This is the maximum dollar amount a dental plan will pay toward the cost of dental care within a specific benefit period (usually January through December). The patient is personally responsible for paying costs above the annual maximum. Consult your plan booklet for specific information about your plan.
Most dental plans have a specific dollar deductible. It works like your car insurance. During a benefit period, you personally will have to satisfy a portion of your dental bill before your benefit plan will contribute to your cost of dental treatment. Your plan information will describe how your deductible works. Plans do vary on this point. For instance, some dental plans will apply the deductible to diagnostic or preventive treatments, and others will not.
Many insurance plans have a coinsurance provision. That means the benefit plan pays a predetermined percentage of the cost of your treatment, and you are responsible for paying the balance. What you pay is called the coinsurance, and it is part of your out-of-pocket cost. It is paid even after a deductible is reached.
Many dental plans offer three classes or categories of coverage. Each class provides specific types of treatment and typically covers those treatments at a certain percentage. Each class also specifies limitations and exclusions (see headings on these elsewhere in this section). Reimbursement levels vary from plan to plan, so be sure to read your benefits information carefully. Here is the way the three levels typically work:
Class I procedures are diagnostic and preventive and typically are covered at the highest percentage (for example 80 percent to 100 percent of the plan’s maximum plan allowance). This is to give patients a financial incentive to seek early or preventive care, because such care can prevent more extensive dental disease or even dental disease itself.
Class II includes basic procedures — such as fillings, extractions and periodontal treatment — that are sometimes reimbursed at a slightly lower percentage (for example, 70 percent to 100 percent).
Class III is for major services and is usually reimbursed at a lower percentage (for example, 50 percent). Class III may have a waiting period before services are covered.
If your dental care will be extensive, you may ask your dentist to complete and submit a request for a cost estimate, sometimes called a pre-treatment estimate, a preauthorization or prior authorization. This will allow you to know in advance what procedures are covered, the estimated amount the benefit plan may pay for treatment, and your financial responsibility. A pre-treatment estimate is not a guarantee of payment. When the services are complete, and a claim is received for payment, insurers may consider eligibility, maximum, any deductible requirements, as well as any limitations, exclusions, etc.
Limitations and Exclusions
Dental plans are designed to help with part of your dental expenses and may not always cover every dental need. The typical plan includes limitations and exclusions, meaning the plan does not cover every aspect of dental care. This can relate to the type or number of procedures, the number of visits or age limits. These limitations and exclusions are carefully detailed in the plan booklet and warrant your attention. This booklet can help you develop realistic expectations of how your dental plan can work for you.
Allowances for some procedures covered under your benefits may be subject to limitation or denial based upon clinical criteria applied by the insurance company’s licensed dentist or consultant staff. Insurance companies generally maintain written guidelines for the use of clinical criteria in making benefit determinations. You may obtain a copy of such guidelines from the insurance company by sending a request in writing for the specific benefit category or dental procedure range.The materials provided to you by the insurance company are guidelines used to authorize, modify or deny coverage for persons with similar illnesses or conditions.Specific care and treatment may vary depending on individual need and the benefits