Dental Insurance

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Dental Insurance 2017-03-17T19:37:08+00:00


Dental Insurance in Our Office

We are in-network with nearly all PPO dental insurance plans.  We do not accept HMO dental insurance.  Below is a sample of the dental insurance plans that we accept and are in-network providers.

Useful Information Regarding Dental Insurance

Regular visits to our dental office can improve your dental health and if you have coverage, you’re more likely to visit your dentist. Those visits can help prevent and monitor dental health issues that could lead to more serious conditions and require more expensive treatment, such as cavities, tooth removal, root canals and even oral cancer.

The good news is that Americans have more choices for dental coverage than ever. Though many people with dental benefits get them through their employers, individual plans are also available through the new Health Insurance Marketplaces established by the Affordable Care Act.

It’s important to know all your options when choosing the right dental insurance for you and your family.

For some people, buying dental benefits may cost more than paying a dentist’s office directly. When considering a plan—especially if it’s not provided through your employer—ask yourself the following questions to estimate how much you might spend out-of-pocket:

•    What is your plan premium?
•    What is your plan’s deductible?
•    What is your co-payment?
•    What percentage of treatment costs (coinsurance) will I pay?

When you consider the total cost of your dental treatment, you must remember to include the cost of dental insurance itself.

Another important factor to consider is what kind of care you regularly receive from your dentist. Are your regular checkups enough, or do you routinely need procedures (like cavity fillings) performed? Talk to your dentist about your dental history and possible care needs before making your decision. Because your health is always changing, revisit these conversations with your dentist before your policy is renewed each year, or when it’s time for you to choose your benefits at work when you’re hired or during open enrollment.

Dental benefit plans are not designed to cover all dental procedures. Plans usually cover some, but not all, of your dental costs and needs. Many plans involve a contract between your employer and dental insurance, but you can also purchase individual plans on your own or through the Health Insurance Marketplaces.

Your dentist’s main goal is to help you maintain good dental health, but not every procedure your dentist recommends will be covered. To avoid surprises on your bill, it is important to understand what and how much your dental insurance will pay.

Even for covered services, most plans share the costs of treatment with you. If you have benefits through work, the amount is determined by how much your employer pays into the plan. If you have an individual plan, the terms will be spelled out in a contract.

Although you may be tempted to make dental care decisions based on what your plan will pay, the least expensive option is not always the healthiest option. Before committing to a plan, make sure you understand how you and your plan share costs. This is done in several ways:

A deductible is typically applied to all services and must be paid by you before your plan coverage starts to pay. Most plans don’t require a deductible for preventive and diagnostic services.

In most cases, you will be expected to pay a percentage of the dentist’s charges or allowed benefit amount. This is called coinsurance. For example, your plan may pay 80% and you pay the remaining 20% owed to your dentist.

Annual Maximums
This is the maximum dollar amount a plan will pay during the course of the plan year. You pay anything over that dollar amount. For example, if your annual maximum is $1,500 and your dental expenses top $3,500, you are responsible for that additional $2,000. If the annual maximum of your plan is too low to meet your specific needs, you may want to ask the plan how you can get a higher annual maximum.

Also, if your plan covers braces, there is usually a separate lifetime maximum limit.

Pre-Existing Conditions
Your dental insurance may not cover conditions you had before enrolling even through treatment may still be necessary. You would be responsible for paying these costs.  For example, benefits may not be paid for replacing a tooth that was missing before the effective date of coverage.

Fixed Dollar Amount (Capitation) Programs
In these programs, you pay a fixed dollar amount for each dental visit or specific treatment. The rest of the treatment cost is covered by the program.

PPO and DHMO: alphabet soup or dental insurance? Sorting through different dental plans can sometimes feel overwhelming. Get a breakdown of your options, and find out which one is best for you.

Preferred Provider Organization (PPO)
A PPO is dental insurance that uses a network of dentists who have agreed to provide dental services for set fees. The number of dental services covered depends on the plan. If you have a PPO plan and see a dentist out of the network, you will most likely have more out of pocket expenses.

Dental Health Maintenance Organization (DHMO)
A DHMO is like an HMO. Network dentists are paid a set fee every month to provide covered dental services to you whether you see the dentist or not. Typically, some of the covered services have no cost to you, or you may have to make an out of pocket payment for the service. 

Discount or Referral Dental Insurance
Discount and referral plans are technically not benefit plans. The company selling the plan contracts with a group of dentists. These groups of dentists agree to discount their dental fees. Discounts are usually applied to all services including cosmetic. These plans do not pay for any services received, instead, you pay the full cost of treatment at the reduced rate determined by the plan.

You know you want dental coverage, but you might not be sure which coverage is most important. Use the questions below to narrow down your needs and find the right plan for you.

  • Can you choose the dentist that you want?
  • Will the plan allow for care by specialists?
  • Are there restrictions or limitations on coverage if treated by a specialist?
  • What are the total costs for the plan which include the premium, co-payments, coinsurance and deductibles?
  • Is there a deductible? If so, how much is it, and how is it applied?
  • What is the annual maximum the plan will pay? Is it an annual or lifetime maximum?
  • Is there an out-of-pocket limit? If so, how much is it?
  • What limitations does the plan place on pre-existing conditions?
  • Does the plan covercrowns, root canals, oral surgery and treatment of gum disease? What are the limitations to the coverage?
  • Does the plan coverbraces? Are there limitations?
  • Aredentures, bridges and implants covered? What are the limitations to the coverage?
  • Does the program provide for emergency treatment? Are there arrangements for emergency care away from home?

Seeking advice from your dentist on the status of your dental health and care needs may help you select the best plan for you.

Some patients have two or more dental benefit plans. So what happens when you’re entitled to additional benefits? Something called coordination of benefits takes place.

What is COB? 
Coordination of benefits (COB) is simply the sorting out of which plan pays what for a patient’s dental care. Benefits from all sources should not exceed 100% of the total charges. When both plans have a COB clause, the plan in which the patient is enrolled as an employee or as the main policy holder is considered primary. The plan in which the patient is enrolled as a dependent would be secondary. Sometimes state laws and regulations determine coordination of benefits, or the plans will coordinate the benefits to eliminate overbilling or duplication of benefits.

When Does Secondary Pay?
Usually, the secondary will not accept a claim until after the primary claim is paid. In most cases the secondary policy will require a copy of the primary plan’s payment explanation, commonly referred to as an EOB (explanation of benefits).

Which Plan Pays for Your Children?
The policy that pays first for dependents is decided by dental insurance or state laws. The primary plan for covering your children depends on the regulations in your state. Most plans use the “birthday rule” (the spouse with a birthday occurring earlier in the calendar year is primary). Others consider the father’s plan primary. In the case of divorced/separated parents, the court ruling is the decision maker.

Finding the right dental coverage can sometimes feel like you’re piecing together an elaborate puzzle. Still, the most important pieces of the big picture are often found in the terms used to outline a plan’s features. Not sure what they all mean? We’ve got you covered.

Annual Maximums
This is the total dollar amount dental insurance will pay during the plan year. Your employer or dental plan makes the final decision on maximum levels of payment. You are expected to pay copayments and any costs above the annual maximum. An annual maximum is usually $1,000 or $1,500 and has not changed much in the last 50 years. These totals are usually for one person. Each family member usually has a separate annual maximum.

Assignment of Benefits
This takes place when you authorize dental insurance to forward payment for a covered procedure directly to the treating dentist.

Cost Sharing
When the treatment cost is shared by the plan and the enrollees, the cost of the plan will be much less. Different ways to share costs include deductibles, co-payments, frequency limitations, annual maximums and use of a fee schedule to calculate benefit payments.

A deductible is the amount of money that you must pay before a benefit plan will pay for any service. (For example: If your deductible is $50, your plan kicks in once you’ve paid that much in related expenses.) Most dental insurance is based on a calendar year (January through December) which means you pay a deductible once each year. It can take more than one service or visit to satisfy the entire deductible. Depending on your dental insurance’s design, some services (such as cleanings and diagnostic services) may not be subject to any deductible.

Exclusions are dental services that are not covered by the plan.

Frequency Limitations 
Each plan contains a list of conditions or circumstances that limit or exclude services from coverage. Limitations determine how often a particular service is covered and are related to time or frequency (the number of procedures permitted during a stated period). For example, no more than two cleanings in 12 months or one cleaning every six months.

Least Expensive Alternative Treatment (LEAT)
If a plan has a LEAT clause, the plan will only pay for the least expensive treatment if there is more than one option to treat the condition.

Pre-existing Conditions
Dental insurance may not cover conditions that existed before you enrolled in the plan. For example, benefits may not be paid for replacing a tooth that was missing before the effective date of coverage.

When reviewing dental benefit plans you may come across terms that you are not familiar with.  Don’t feel intimidated. The chart below shows terms frequently used in dental benefit plans and compares them to the terms you may commonly associate them with.

Dental TermCommonly Known As
Amalgam RestorationSilver Filling
BruxismTooth Grinding
Composite RestorationTooth Colored Filling
EndodonticsRoot Canals
ExtractionTooth Removal
GingivitisEarly Gum Disease
Gingivoplasty/GingivectomyGum Surgery
Impacted ToothTooth Buried in Bone
Maxillofacial SurgeonOral Surgeon
Osseous SurgeryBone Surgery
Partial DentureRemovable Bridge
PeriodontitisAdvanced Gum Disease
ProphylaxisTeeth Cleaning
Scaling and Root PlaningDeep Cleaning
SealantsPlastic Coating on Teeth

Healthy teeth and gums are important for you and your children. Dental disease can affect your overall health, so it’s important that you and your children see a dentist regularly to stay healthy.

The Affordable Care Act requires that the new health insurance marketplaces offer dental insurance for your children. Although the new act does not require dental coverage for adults, some state marketplaces may also offer dental coverage for adults.

Enhancements to Coverage
The ACA prohibits dental insurance from using annual or lifetime dollar maximums on children’s dental coverage. In the past, many plans had an annual or a lifetime maximum which capped the amount of dollars the plan would pay on an annual or lifetime basis. You had to pay the cost of care over those limits, but that’s no longer the case for pediatric dental benefits.

The ACA also eliminated exclusions for pre-existing conditions as of 2014. This means that plans cannot deny coverage because of a condition you already had when you enrolled in the plan.

Securing Dental Coverage
In the Health Insurance Marketplace, you can get dental coverage as part of a medical plan (and pay one premium) or by itself through a separate, stand-alone dental insurance (and pay an additional premium). In some states, such as California, all medical plans embed pediatric dental benefits. In these states, you will always get dental coverage through a medical plan and have the option of purchasing additional coverage through a stand-alone plan. In other states, such as Washington, you can only get pediatric dental benefits coverage through a stand-alone dental insurance.

High and Low Categories of Dental Insurance

  • The high option dental insurance has a higher premium but lower copayments and  You will pay more on a monthly basis and less when you actually use dental services.
  • The low option plan has a lower premium but higher copayments and deductibles. You will pay less on a monthly basis and more when you actually use dental services.

Out-of-Pocket Limit for Children
Remember, dental insurance is not designed to cover all dental procedures. Many of the procedures that are covered are not covered at 100%, meaning that you will have to share in the costs for those procedures. This is partially accomplished through out-of-pocket costs like deductibles and coinsurance.

If you purchase dental insurance separately from your medical plan, you will have a separate out-of-pocket maximum that applies to your children’s stand-alone dental insurance. The out-of-pocket limit is defined as the total amount of money you will need to pay for your dental care including deductibles, coinsurance and copayments. The out-of-pocket maximum is $350 for one child and $700 for two or more children. After you reach this amount the dental plan must pay for all additional covered expenses for the rest of the plan year.

Links to Help You Choose Marketplace Insurance has a number of resources available to help you choose the plan that best fits you. Use these resources when making your decision.