Dental Insurance Terms
Dental insurance provides wonderful benefits. However, there are numerous confusing provisions in the “fine print” of most contracts. Some common terms to know & understand:
- Deductible: How much you have to pay before your insurance begins to kick in. (Commonly $50-200). Some “categories” such as preventive services & exams may have no deductible, whereas other categories may have different amounts.
- Maximum: The most you can spend of your insurance company’s money each year. (Usually $1000-$1500)
- Categories: Carriers often present percentages based on 3 “categories” of services:
- Diagnostic: Exams, X-rays, simple cleanings – usually covered at 80-100% of the insurer’s fabricated fee.
- Basic: Fillings, Root canals- usually covered at 60-80% of the carrier’s assigned fee.
- Major: Crowns, Bridges, Dentures, Gum treatment- usually covered at 0-50% of the artificial insurance fee.
- UCR Fees: The artificial fee your carrier assigns to each dental procedure. When your plan “says” it will pay 80% for a filling, it will pay 80% of this assigned fee, not what any dentist actually charges. There are virtually no regulations governing whether those fees are fair or realistic.
- Exclusions: Dental treatments that are not covered. Common examples include Dental Implants, various Cosmetic Services, certain Treatments for Gum Disease, & TMJ-Bite therapy. Over half of all the dental codes are excluded from most contracts.
- Alternative Benefits: If there are several ways to fix your dental problem, your carrier will pay for the least expensive option, even if you pick better care.
- Frequency Limitations: Coverage is commonly denied if your insurance paid for your procedure before. For example, your contract may indicate that your insurer will pay for the redo of a filling once every 7 years; or of a crown or denture every 10 years. Even if you need the treatment sooner, insurance may be exclude coverage.
- Pre-existing conditions: refer to dental problems that you had before your benefits became effective, where treatment may not be covered. A common example is denial to replace a tooth you lost before you had your dental insurance.
- Bundling: is when Insurance ignores specific treatment codes submitted by your dentist, gathers them as if they were a single treatment & pays on that only. A common example is various procedures bundled into one for Oral or Periodontal Surgery.
- Medical Necessity: is when your contract specifies that treatment is not covered for a specific problem, whether it is needed or desired. A common example is for a root canal on molar teeth or Gum Procedures.
- Better Plans: Your neighbor may have the identical problem you have, but a better insurance plan. A different insurance company or even the same carrier may pay the neighbor more if his/her contract assigns a higher fee, fewer exclusions etc.
- Need Verses Contract: Your dental coverage is based solely on the legal language in your contract; not your health needs. The more your employer paid for coverage, or the higher your premiums the better your plan will be.
Common Questions About Dental Insurance
1. How does dental insurance work?
Dental Insurance will help pay for SOME of your dental needs. The more your employer paid for coverage, the better your plan will be. Whatever your benefits, they are a wonderful gift to have.
2. How are plans different?
Most plans have co-payments, deductibles, maximums, and excluded services. Please refer to our “Dental Insurance Terms” section, for explanations & examples of these confusing features.
3. I reached my maximum in no-time. Is that normal?
The common $1000-$1500 maximum was set 50 years ago as a “reasonable” level of dental coverage per year & has not increased since. Many people need care that far exceeds this artificial maximum.
4. If I don’t have coverage, it must not be necessary – right?
No. Your insurance contract is designed by lawyers and financial experts to control costs. The limitations of your policy have no relation to the treatment that you need or want. It is your dentist’s responsibility to advise you what treatments are available and what is best for you.
5. My insurance will pay only for a cheaper treatment. Should I get that instead?
Insurers commonly pay for the “least expensive alternative treatment.” Many times, this is not the smartest or best choice. Your dentist will help you make the best decisions for your care.
6. Why can you only estimate my coverage?
Many carriers do not release accurate details of their plans, or disclose what they will pay for treatments. It is a great frustration for everyone.
7. Should I ask for a written estimate?
The process is designed to be cumbersome so that around 70% of treatment that is estimated in writing never gets done. Many dentists consider pre-estimates a waste of time, as they do not guarantee coverage.
8. How much is dental insurance?
At only about $40-60/ month for family coverage. If your plan is disappointing, consider showing your employer this write-up. They may not be aware of the restrictions and fine-print in the contract they purchased. Better benefits may cost only a bit more.
9. What if my spouse has insurance?
At one time “double insurance” would nearly double your coverage. Today, you will commonly get little additional coverage from a second plan.
10. Do dentists take medical insurance?
Medical plans do not cover dental services, except for a few situations, such as accidents and some oral surgery.
11. How do dentists get on the list of “preferred providers”?
Providers are screened for major legal violations; but for the but for the most part all they have to do is agree to accept lower reimbursements.
12. Can Dentists waive my portion & accept whatever insurance pays?
This may seem reasonable and innocent, but it is actually illegal for your dentist to do so, as it is considered falsified billing. Carriers audit records for such activity and prosecute violators.
13. Can you change codes, or dates, to get me better coverage?
No, this is fraud. Insurance carriers can inspect records, x-rays, lab slips & other records. You and your dentist can be fined or imprisoned.
Dental Insurance Companies
Insurance companies may have numerous plans & coverage can change often. Benefits & carriers vary by state and region. Please contact your Dental Practice directly to see how they work with your specific plan. The following are some of the major Dental Carriers:
Blue Cross/Blue Shields (Various states)
Delta Dental Premier
Dental Health Alliance
Dental Care Plus
Dental Health Services
Dental Network of America
Kansas City Life
Life & Specialty Ventures
Mutual of Omaha
Principal Financial Group
Sun Life Financial
Spirit Dental & Vision
United Service Association
In-House Dental Plan