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Understanding Dental Insurance

 

Here’s a quick overview of how most dental insurance works. Be sure to look at your plan booklet for the specifics of your plan’s benefits and coverage.

 

Plan Basics

 

  • Dental carriers offer a variety of benefit plans, each with different features. So while a plan may have 100% coverage or no copayments for checkups and cleanings, another plan may not.
  • Many dental carriers offer a fee-for-service that allows members to visit any licensed dentist, but you will usually save the most when you visit a dentist in your plan’s network. Your dentist will submit a claim after your visit and will not bill you more than the approved amount. If you visit an out-of-network dentist, you may be responsible for paying your dentist the full amount and submitting the claim to the insurance company after the visit.
  • You might have benefits from more than one dental plan, which is called dual coverage. In this situation, the total amount paid by both plans can’t exceed 100% of your dental expenses. And in some cases, depending on the specifics of the plans, your coverage may not total 100%.
  • Most dental plans work within a “benefit period” that is typically one year — but not necessarily a calendar year.

Things to Know

 

Deductible

Similar to car insurance, this is the amount you have to pay before your benefit plan begins to pay the cost of your dental treatment. Some plans have an annual deductible and some may have a lifetime deductible.

 

Maximums

This is the maximum amount of money a dental plan will pay for dental care within the benefit period. Once you reach the maximum amount, you are responsible for paying any costs for the remainder of the benefit period.

 

Coinsurance

If you have a fee-for-service benefit plan, the plan pays a percentage of the treatment cost, and you are responsible for paying the balance. What you pay is called coinsurance, and it is part of your out-of-pocket cost after your deductible is reached.

 

Reimbursement Levels

Fee-for-service dental plans offer different categories of coverage, each tied to a certain percentage. For example:

Diagnostic and Preventive Procedures (such as cleanings and checkups) are typically covered at the highest percentage (for example, 80 to 100% of the plan’s contract allowance). This gives you a financial incentive to get regular checkups and cleanings to prevent the need for more extensive procedures.

 

Basic Procedures (such as fillings and a tooth extraction) are usually reimbursed at a slightly lower percentage (for example, 70 to 80%).

 

Major Procedures (such as crowns, root canals and implants) are usually reimbursed at a lower percentage (for example, 50%).

 

Copayment

You pay a fixed dollar amount for certain covered services (some services may have no copayment), instead of a percentage. When you enroll, you receive a list of covered services and their copayment amounts. These types of plans usually have no annual deductibles and no maximum amounts for covered benefits.

 

Pre-Treatment Estimate

If your dental care is extensive and you want to plan ahead for the cost, you can ask your dentist to submit a pre-treatment estimate. This estimate includes an overview of services covered by your dental plan and how coinsurance, deductibles and dollar maximum limits might affect your share of the cost. While it is not a guarantee of payment, a pre-treatment estimate can help you predict your out-of-pocket costs.

 

Limitations and Exclusions

Dental plans are intended to cover part of your dental expenses, so coverage may not extend to all of your dental needs. A typical plan has limitations such as the number of times you can receive a cleaning each year. In addition, some procedures may be not be covered at all, which is referred to as an exclusion. Review your plan booklet and obtain a pre-treatment estimate to see how any limitations or exclusions would affect your share of the cost.