Dental insurance can be confusing, we get it. And while the professionals at your dental office are well-versed in dental insurance and are here to help break down your benefits and answer any questions, it is always a idea good to have an understanding of your dental policy. Not only will you be empowered with knowledge, but this can help eliminate anything being missed or miscommunicated between the insurance company and your dental office in regards to the “fine print”, or clauses and addendums. Mistakes happen, we are human. So you can help yourself by being in the know.
Understanding Dental Coverage
Here’s a quick overview of how most dental coverage works:
Most dental plans work within a “benefit period” that is typically one year — but not necessarily a calendar year.
Things to know
Similar to car insurance ore medical insurance, this is the amount you pay before your benefit plan begins to pay the cost of your dental treatment.
A deductible usually doesn’t apply to diagnostic and preventive treatment.
This is the most money a dental plan will pay for dental care within a benefit period. Once you reach the maximum amount, you’ll pay any costs for the remainder of the benefit period. The majority of dental plans have a yearly maximum of 1,000-2,000 yearly.
If you have a fee-for-service benefit plan, your plan pays a predetermined percentage of the treatment cost and you’re responsible for paying the balance. This part of your out-of-pocket costs is known as “coinsurance.” You might also have a fixed copay plan, which means there is a fixed fee (not percentage) you pay for each service.
Tiers Of Coverage/Percentage Of Insurance Reimbursement
Fee-for-service dental plans offer different categories of coverage, each tied to a certain percentage. *For example:
Tier 1. Diagnostic and preventive procedures, such as cleanings, x-rays 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.
Tier 2. Basic procedures, such as fillings and periodontal procedures, are usually reimbursed at a slightly lower percentage (for example, 70% to 80%).
Tier 3. Major procedures, such as crowns and root canals, are usually reimbursed at the lowest percentage (for example, 50%).
*The percentages of coverage laid out above are an average; Procedures can be covered under different categories and percentages depending on your plan, and some plans have additional tiers. Please see your plan booklet or Policy for a complete description of benefits, limitations and exclusions.
If your dental care is extensive and you want to plan ahead for the cost, you can ask your dental office to submit a pre-treatment estimate. This estimate includes an overview of services covered by your dental plan and how any applicable coinsurance/copayments, deductibles and dollar maximum limits might affect your share of the cost. Some insurance companies require a pre-authorization for certain procedures, although this is never a guarantee of payment. Most procedures do not require pre-authorizations.