When presented with dental insurance coverage many people get confused about what is being covered. This is very understandable since dental insurance works much different than other insurances you may have: medical, auto, life, etc. Hopefully in this post we can shed some light on the differences and help you understand what you are paying for.
- Dental insurance has an annual maximum they will pay. Once you hit this limit they will not pay for anything else; this includes cleanings. Medical and auto insurance usually work contrary to this giving you a deductible to m eet before they start covering things. In medical and auto insurance once you meet your deductible the maximum is typically very high so it covers you in large unexpected events. Most dental insurances annual maximum are usually much lower between $1000 and $1500, which after they pay leaves the patient with any further dental costs. Annual maximum benefits are usually reset on January first, however some policies will renew in other months. In addition any unused amount expires and cannot be carried over into the next year. So if you are paying for dental insurance and don’t go for 5 years and decide to come in and need 3-4 crowns, more than likely your insurance will max out even though you never used it for 5 years.
- Dental insurance splits procedures into different categories and pays different amounts on them. Typically, the larger and more complex the procedure, the less the insurance will pay. Below is a very common coverage example for insurance
- Preventative and Diagnostics (Cleanings and x-rays) = 100%
- Basic Restorative (Fillings) = 80%
- Major Restorative (Crowns) = 50%
- Prosthodontics (dentures and partials) = 50%
- Some policies pay for a less expensive alternative to some procedures. For example, while many dentists recommend white fillings, most insurance policies will only pay for silver behind your canines. The same is true for crowns, a dentist may recommend a certain material, however the insurance will base their percentage on a lesser material paying less.
- Policies can also have exclusions and limitations. Some policies will make you wait a year before paying for a crown or bridge. Another example is a missing tooth clause where they will not pay for a bridge over a tooth you had extracted prior to that insurance being active. There are often limitations on how soon you can have a crown redone if needed. Insurance limitations also determine how frequently you can have cleanings, exams, x-rays, etc.
- The deductible for a dental insurance policy is usually between $25 and $100. It is usually taken out of the cost of the procedure and then insurance pays based on the remaining portion. Here is a concrete example, say we have a procedure that costs $150 and insurance is going to cover 80%, subject to the deductible of $100. $150 – $100 = $50. 80% of $50 is $40. That leaves the patient with $110 to pay while the insurance is paying $40.
- You may find yourself asking what is in network vs out of network. In network means the dental office and the insurance company have sat down and agreed on what should be charged for each procedure. Out of network means this negotiation has not happened (for several possible reasons). This makes it more difficult for an office to estimate the patient portion because the out of network insurance company does not disclose the amount beforehand. While the insurance says it will be paying 50% of a procedure they may be basing it on a lesser amount and leaving you with the rest.
Hopefully this sheds a little light on how dental insurance works. If you have specific questions about your policy feel free to give us a call (205-267-1216) and we will be happy to check your insurance and explain it to you.