One of the most common questions that we get in the front office is "does my insurance cover that?" And for good reason - insurance can get complicated! So I decided to write a blog (or two, or three) on the basics of dental insurance.
When you call our office to make an appointment, and if you are one of the lucky few that even HAVE dental insurance, we will get your insurance company to get what we call a "breakdown" of your benefits, basically, what your insurance covers. Every policy is different, and we spend a lot of time trying to get as much information about your policy as possible, so that when we are discussing your treatment options with you, we can give you accurate information about how much your insurance is going to cover and whatever treatment the doctor is recommending.
Here is some of the information we get about your policy:
Deductibles and Maximums:
The
benefit year is when your benefits begin and end. Usually the benefit year is from January 1 to December 31 each year, but some policies do have unusual start and end dates, like September 1 to August 30th, for example.
The
maximum is the amount that your insurance company will pay toward your treatment in during your benefit year. Most policies are in the $1,000 to $1,500 range. If we say that your benefit year is January to December, and you have a max of $1,000, it means that your benefits renew every January 1st, every January 1st you have a new $1,000 to use during that year. During the year your insurance company will pay a MAXIMUM of $1,000. There is NO "rollover" of dental benefits. If during 2011, your insurance only paid $500 towards any dental treatment you got, that other $500 was gone as of December 31st, 2011. It does not carry over. On January 1, 2012, your benefits renewed and you have another $1,000 to use, but that $500 that you didn't use last year....so long!
Most plans have a yearly
deductible. It is usually around $50 per person, but I have seen some as high as $100, and some with no deductible at all. Your deductible works a lot like your maximum, it is a yearly deductible. You pay it once per year. So if you plan has a deductible, you will be paying your deductible at your first appointment for the year for dental treatment. After that first visit, you have met your deductible for the rest of the year, so you will not be paying a deductible every time you come in, only on the first visit of the year.
Preventive and Diagnostic:
"Preventive and Diagnostic" procedures are just that....procedures that help the doctor make a diagnosis, and other preventive services. The most common items that fall into this category are your
exams with the doctor, xrays, and basic cleanings. Other diagnostic services could be biopsies and cultures (like if the doctor notices an unusual-looking bump or spots in your mouth or on your tongue, and wants to get it sent to a lab to have it checked out). Most insurance companies will cover your exams, xrays and basic cleanings wit the doctor at 100%. However there are some limitations....
Frequencies:
Dun Dun Dun....already the insurance is getting complicated! Yes, they usually say that your cleanings and exams are covered at 100%, but there is a limit! Most preventive and diagnostic services have a
frequency limitation, which means they will only cover it every so often. The most common example of this is exams, basic cleanings, and xrays.
For example, most insurance companies will pay for TWO exams per year. So say you come in January for your cleaning and checkup. The hygienist cleans your teeth and then the doctor does an exam to make sure everything is looking ok, checking for any cavities, cracked teeth, etc. You come again in July, six months later, for your second cleaning and checkup of the year. Then in October you get hit in the face with a piece of equipment at work (this really happened to one of our patients!) and you have a broken tooth, and you need to see the doctor to see what he can do to fix it.
Well guess what?! Your insurance company has already paid for two exams that year, so they might not pay for this third exam. The other thing they are sticklers on is the xrays. The bitewing xrays are only covered twice per year (usually), and the panoramic xray (the large on that shows your entire mouth) is usually covered only once every 3 years.
Basic Services:
Basic services pretty much means
fillings. Most insurance companies cover 80% on fillings. HOWEVER, one thing that we see a lot of is that insurance companies are not paying for composite fillings, which are the tooth colored fillings, and will only pay for amalgam, which are the silver fillings.. Sometimes they just don't pay for white fillings at all, but a majority of the time they "downgrade" the white filling to a silver filling.
So you come in, you have a cavity, you get a white filling, which has a fee of $100. If they cover at 80%, they should pay $80 and you would pay $20, right? WRONG! We bill your insurance company for the white filling, $100. They say, well, we don't cover white fillings, but we will pay on that filling, like you got a silver filling. The fee for a silver filling is $75. So instead of paying $80, they are going to pay 80% of the silver filling fee, $60. Now YOU, the patient, has to pay the difference between what your insurance company is paying on the silver fillings ($60), and the fee on the white filling (the original $100), which means you pay $40 instead of $20. The insurance companies do this in order to avoid having to pay for your treatment [rant: and to give me a headache, I swear! If your policy does this, you should call and complain or write them a letter and complain about it! Why should they not have to actually cover the treatment you received? Why should they be able to pay less and leave you with the balance? If they are going to say they cover at 80% for fillings, and the doctor is recommending a white fillings, why should they be able to say "well we think this alternative treatment is better because it costs us less so we are only going to pay AS IF you got this lesser treatment"?!?! end of rant :) ]
Major Services:
Major services include
crowns, bridges, dentures, partial dentures, and sometimes
dental implants.
Most insurance companies cover these services at 50%, which means that they pay half and you pay half.
Endodontics and Periodontics:
Endodontics
services are anything related to the nerve, which most of the time means
root canal!
Periodontics services are procedures to treat periodontal disease (aka
gum disease).
Most insurance policies cover both of these categories at 80%, but I have seen some at 60% and even some at only 50%.
Orthodontics:
There are a lot of policies that don't cover
braces at all. But if they do, most have a separate maximum, in addition to your regular maximum I talked about above. The max is usually $1000. There is also usually an age limit, usually around age 23. This means they will only pay for braces on people under that age limit. Unlike your regular yearly maximum that I talked about above, the orthodontic maximum is a LIFETIME max. It doesn't renew every year. It's a one-time thing. For instance, your son is 13, he needs braces. The total fee on the braces is $3,000. Your insurance will pay $1,000 (the orthodontic maximum). The patient is responsible for the other $2,000. Now that they have paid the $1,000 max, they will never pay for braces on that son again, because its a lifetime maximum, not a yearly one.
Wow this turned out to be a novel! So these are the basics. I think I will go into more detail on a few things in later posts. But if you have any specific questions about your insurance policy, please feel free to call our office at 915-778-4681 and we can help you understand your dental policy. Thanks for reading!
