10 Things You Need to Know About Dental Insurances
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DENTAL INSURANCE IS NOT LIKE MEDICAL INSURANCE
Some people refer to dental insurance as a dental “benefit” or a dental coupon instead of insurance.This is why.
With MEDICAL INSURANCE, there is generally a deductible, co-pay and an out-of-pocket maximum that the patient is responsible for…after that, medical insurance covers the rest.
With DENTAL INSURANCE, there is often a deductible and co-pay: however, dental insurance has an annual maximum the insurance company will pay, after that, the PATIENT is responsible for the rest. This is why dental benefit or coupon is more accurate.
Another area where medical and dental insurances differ, is that with dental insurance often they have limits on work that is allowed. These maximum benefits have not increased in over fifty years, since dental insurance was introduced in the 60's. ($1000.-$2000.) What do you know that you can buy today at the same price as you could of in the 60's?
Some dental insurance companies will not allow more treatment on the same tooth for 5, 7, and even up to 10 years, whereas, with medical insurance they continue to pay for treatment as needed. Other limits might be the restriction of the number of times that you can receive x-rays and other treatments you may need. For instance, you might need 3 or 4 cleanings a year if you have periodontal gum disease and your insurance company will probably only pay for two. That doesn't mean you don't need to have the 3 cleanings, it means that your dental benefits, depending on your plan, will only pay for two. Dental insurance benefits are not based on health prevention or necessity but rather ways to limit liability in favor of insurance profitability to shareholders.
ALL DENTAL INSURANCE POLICIES ARE NOT THE SAME, EVEN WITHIN FAMILIES AND COMPANIES
Every insurance policy is different. The same dental plan company may have many different levels of benefits, for example a Platinum, Gold or Silver pIan that companies or individuals can choose from.
At the annual renewal date, an employer might keep the same insurance company but select a lesser plan. Be sure that you are familiar with your particular plan and are aware of the benefits, limitations and the annual renewal date of your policy. Anytime you receive a new card or number you should clarify whether your benefits have changed. Also, be aware that benefits may be different for each member of your family.
Being aware and staying in touch with your insurance agent or your HR person will help you stay informed. Dental offices will never be informed of such changes because the contract is between you and the insurance company not with the dental office.
WHAT DENTAL INSURANCE USUALLY COVERS
Dental insurance generally offsets the cost of treatment but doesn’t pay for it entirely. On average, dental insurance covers 80-100% of preventative (cleaning, exam, and x-rays), up to 80% of restorative (minor fillings) and up to 50% of major work (crowns and bridges), but when you factor the allowable fee into this, it can decrease coverages by a 20-30% decrease of stated benefits AND if insurance can deem any procedure cosmetic dentistry, it will generally not cover anything at all.
DENTAL INSURANCE HAS AN ANNUAL CAP & NO ROLLOVER COVERAGE - USE IT OR LOSE IT
Most dental insurance has a cap of what they will pay annually, usually between $1000 - $1500. It’s interesting that when dental insurance came into being in the early ‘60’s, the cap for benefits was the same, $1000. That was a time that gasoline cost .23 a gallon and the average cost of a new house was $12,950. Be sure that you are aware of your annual cap and how much of it you have used each year. If you don’t use it, you lose it.
NO ONE KNOWS EXACTLY WHAT YOUR INSURANCE
IS GOING TO PAY
”My dentist office told me that I owed one amount, but now I have a bill for more. I thought my insurance company was supposed to cover this!”
This is the frustration that patients and dental offices share.Dentist offices, as your insurance advocates, do their best, spending hours calling insurance companies and getting ‘estimates' of what they will cover. However, on each estimate they receive it says
”This estimate is not a guarantee of payment.” Even if YOU call your insurance company to see if your treatment will be covered, they will say that their estimate is not a guarantee of payment, some policies even state that “downgrades vary per patient”.
DENTAL INSURANCE HAS A WAITING PERIOD
Dental Insurance often has waiting periods before you can use it. People are often very excited about receiving dental insurance if they haven’t had it in a while. Just be aware that there can be a 6-18 month waiting period before it goes into effect on certain procedures.
WHY YOUR INSURANCE DIDN'T PAY WHAT YOU EXPECTED
There are countless ways, that dental offices hear everyday, that insurance companies can find to not pay insurance benefits. The following are just a few of the more popular excuses:
• Your policy did not want to pay for a composite (white-colored) filling, only an amalgam
(black-colored silver-mercury) filling.
• The insurance company decided you did not need a procedure that the doctor identified as necessary or downgraded a procedure code.
• You have not met your deductible
• You have not reached the end of your plans waiting period or are ineligible due to allowed frequencies for coverage.
• You maxed out your plan (used up all your benefits on other procedures) and no longer have coverage until the plan resets at the next renewal date.
WHAT TO ASK ABOUT YOUR INSURANCE PLAN
Does your insurance follow a normal calendar year? (Jan 1-Dec 31) If not, what month and day does your plan year start and end?
• What is your annual maximum benefit dollar amount?
• Are there any waiting periods for benefits to begin or age limitations?
• How often does your plan cover cleanings, exams, x-rays, fluoride, and sealants, fillings, crowns and dentures?
• Does your plan reduce coverage to the rate of old-fashioned amalgam restoration material or does it cover up-to-date tooth-colored composite fillings?
• May I get a copy of my allowable fee schedule?
• What percent does your insurance cover for:
• Basic Restorative?
• Major Restorative Treatment and Prosthodontics?
WHO IS RESPONSIBLE FOR THE BILL?
We will do everything in our power to help you get the most from your benefits. Ultimately, though, you are responsible for the full amount regardless of what your insurance pays.
That is why we encourage you to know your own plan and know that we are dedicated to being your advocate.
IS IT WORTH IT TO GET DENTAL INSURANCE?
YES, if you receive insurance from your employer with no out-of-pocket cost to you, then even if not everything is covered, you are still getting a substantial discount. Purchasing individual dental plans have universally proven to not be worth the premiums given the low maximum benefits.
Keeping your teeth in tip-top condition will extend your life. Regular dentist visits can do more than keep your smile attractive - they can also tell dentists a lot about your overall health, including whether or not you may be at risk for chronic disease. New research suggests that the health of your mouth mirrors the condition of our body as a whole. For example, when your mouth is healthy, chances are your overall health is good, too. On the other hand, if you have poor oral health, you may have other health problems. Research also shows that good oral health may actually prevent certain diseases from occurring.
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