Dental insurance really isn’t insurance at all, merely an aid to help patients with the cost of some dental expenses. True insurance is meant to cover the expenses of unexpected occurrences, not routine events for which you can plan. Dental insurance, on the other hand, offers more coverage for routine services (exams and cleanings) and little coverage for major treatment.
While all plans are different, the standard model for dental insurance is for the plan to have a yearly maximum, a deductible and to cover certain services at certain percentages. Once a patient has reached their maximum, dental insurance will not pay for any more treatment that may be needed for the year. The majority of dental plans have a benefit schedule similar to this:
Quite simply, if you find that certain dental procedures are not covered on your plan it is because your employer purchased a plan that has restrictions on services covered. The more restrictions on a plan, the less expensive the plan is to purchase for your employer.
Dental insurance became available in the late 1960’s and many people are surprised to learn that the yearly maximum on most insurance plans then was $1,000.00 – as it still is today! If dental insurance had kept pace with inflation, the yearly maximum today would be around $5,500! Of course dental insurance premiums have increased since 1960, but the maximums the insurance companies will pay have not. We have few answers to offer as to how insurance companies can rationalize increases in premiums without having to pay out more for coverage.
A yearly maximum is a set amount that a dental insurance company will pay out in a year. While most maximums run on a calendar year, beginning January 1 and ending December 31, some run on a fiscal year. It is an employer who determines if they want the insurance plan to be run on a calendar or fiscal year.
Generally, maximums will automatically renew each year and very seldom will roll over from year to year. In other words, if you do not use your entire yearly maximum, you loose it. Most dental insurance companies allow an average yearly maximum of $1,000.
A deductible is a set amount that the insured must pay before a dental insurance company will pay out any dental benefits. Typically most insurance plans purchased by employers have a $50.00 deductible, so the first $50.00 of dental work an insured has done they will have to pay for.
Many dental plans waive the deductible for preventative procedures, meaning you do not have to pay out your deductible before the plan will pay for routine services, such as cleanings and examinations. It is very helpful to know if your plan waives the deductible for preventative services so you are not surprised to find you owe money for a cleaning or exam.
While all dental insurance plans vary, most insurance companies consider routine cleanings, comprehensive and preventative examinations and standard x-rays as preventative services.
While all dental insurance plans vary, most insurance companies consider fillings, simple extractions and root canals as basic services.
While all dental insurance plans vary, most insurance companies consider dentures, crowns, bridges and partials as major services.
The vast majority of dental insurance plans carry a “missing tooth clause.” A missing tooth clause protects the insurance company from paying for the replacement of a tooth that was missing before the policy was in effect. In other words, if you lost a tooth before you had your dental insurance coverage and then decided you wanted to replace the tooth with a partial, bridge or implant, your insurance company would not cover any of those services if the plan contains a missing tooth clause. Your insurance company may also have a restriction stating they won’t pay to replace a partial, bridge or implant that you had placed prior to having that particular insurance coverage or simply not pay to replace it before a specified time limit has passed.
The vast majority of dental insurance plans will downgrade composite fillings to amalgam fillings when they pay their portion of dental services. To elaborate, there are two main types of fillings: 1.) tooth-colored composite fillings that are made of a resin material and 2.) silver-colored amalgam fillings that are made primarily of mercury and mixed with other metals. Amalgam fillings are made of less-expensive materials than composite fillings and require less of a dentists time to complete. For this reason, they are less expensive than composite fillings. Insurance companies often will pay for procedures based on what is called the Least Expensive Alternative Treatment (LEAT), so if you have a composite filling placed, they will pay their portion of the treatment at the rate of an amalgam filling and you will be responsible for the remaining balance.
After dealing with hundreds of different insurance plans, it is clear that many plans carry the same restrictions. These are:
1. Waiting periods for treatment
2. Missing Tooth Exclusions
3. Least Expensive Alternative Treatment clauses
4. Downgrading to amalgam fillings
5. No coverage for dental implants
6. Limiting the number of cleanings a perio patient can have per year
7. Age limitations for orthodontics, sealants and fluoride
The main reason you should use your dental benefits before the end of the year is because the benefits do not rollover. In other words, most insurance plans have a yearly maximum of $1,000. If you have not visited a dentist for your plan year or have not used up all of your yearly maximum, it will go away. If you are paying for dental insurance premiums every month, it makes sense to get the most out of your benefits.
Also, consider that by delaying dental treatment you are at risk for needing more extensive, and therefore more expensive, dental treatment later. What starts out as a small cavity can turn into a toothache requiring a root canal to fix.
And finally, my last insider’s tip is this – many dentists, like many other businesses, begin the new year by increasing fees to keep up with inflation. Obviously any fee increases can mean higher co-pays for you.
Many patients seem surprised when they tell us they have Delta Dental, for example, that we don’t instantly know exactly what their plan covers. Unfortunately because of the sheer number of dental plans, and the hundreds of restrictions set per plan, it is IMPOSSIBLE to know exactly what an individual’s plan will cover for each dental procedure.
Consider this, in our Cincinnati dental office we have over 70 different Delta Dental insurance companies we deal with listed in our database, each operating independently of each other with different addresses and phone numbers. Within these 70 different Delta Dental Insurance companies, there are hundreds of different insurance plans that each offer, all with unique yearly maximums, co-pays, restrictions, etc.
So even within a particular insurance company, such as Delta Dental, there are literally thousands of different unique plans and knowing the ins and outs of all of these plans is impossible.
Perhaps the hardest aspect of dental insurance to explain to patients is the concept of Usual, Customary and Reasonable (UCR.) Many insurance plans state that they pay their percentage based on UCR fees, not the dentist’s actual fee. The term Usual, Customary and Reasonable is misleading. It implies that the UCR fee that the insurance company sets is the average fee being charged by dentists in the area. THIS IS ABSOLUTELY FALSE! UCR fees are determined by different methods by the dental plan administrators and are often very low compared to the area’s average professional fee for the same services. In fact, insurance companies usually have different levels of UCR fees from which employers can choose.
The best way to explain a plan that pays based on UCR is to look at an example. Company A and Company B both have insurance plans through Acme Dental Insurance. The companies both purchased plans that state they pay 50% of the UCR fee for major services. However, Company A chooses for the UCR fee for a crown to be $600.00 while Company B chooses for the UCR fee for a crown to be $800.00. Company B is paying more for their insurance premium to get this higher level of coverage. Let’s say your dentist’s fee for a crown is $1,000. Many patients think that since their insurance pays 50% for major services, that their co-pay should be $500.00 (half of $1,000) The example below shows how this is not the case with UCR plans.
|Dentist’s Fee||UCR Fee||Insurance will pay:||Patient will owe:|
|Company A||$1,000||$600.00||$300.00 (50% of UCR fee)||$700.00|
|Company B||$1,000||$800.00||$400.00 (50% of UCR fee)||$600.00|