How does dental insurance work?

How does dental insurance work?

On June 23rd, 2014, posted in: Practical Information by

So you have dental insurance, but it all seems a bit confusing. There are categories of coverage, there is a deductible, there is a yearly maximum, and there are “downgrades”- what does this all mean?

First of all, let me explain how dental coverage works from a dental office’s perspective. In our office we only have PPO contracts, which is the most common form of dental insurance. This is the main insurance that I’ll be referring to. If we sign a contract with a dental insurance company, then we are “In Network” with that dental insurance company. This means that the company will list us as an “In Network” dentist, and that you, as the patient, will get the most coverage by seeing us (or another “In Network” provider). In exchange, we agree to charge that insurance company’s fee schedule, which is a significant discount from our normal fee schedule.

If a dental practice is not an “In Network” provider, that does not mean you cannot use your insurance benefits at that office. Your insurance will generally still pay a percentage of your treatment at an “Out-of-network” office, but the fees will not be as low and the percentage that the insurance company pays may not be as high.

A deductible is the amount a patient has to pay before the insurance company will contribute to the cost of the treatment. Deductibles for dental insurance are not as high as medical insurance- they are usually anywhere from $25-$150, or sometimes there is no deductible at all. Also, almost always you will NOT have to pay a deductible for a preventive appointment, and usually this is paid for by the insurance company at 90-100%. This means that you should be able to come in for a professional cleanings and examinations twice a year for little to nothing.

Yearly maximums for dental insurance are often very low. The maximum that the insurance company will pay in one year (usually in a calendar year) is anywhere from $500-$2500. Because of that, sometimes it is better to think of insurance money as a gift card that can be applied to your treatment.

An insurance “downgrade” refers to the insurance company only being willing to pay for the cheapest option to restore your tooth. Sometimes the insurance company will only pay for the metal amalgam fillings or will only pay for all metal crowns of the cheapest metal (“base metal”) rather than paying for tooth-colored fillings or tooth-colored crowns. The insurance company will still contribute to paying for your dental treatment, they just will not pay as much. For example, an insurance policy says that the insurance company will pay for 50% of the cost of a crown. However, they will not pay for 50% of the cost of a porcelain (tooth-colored) crown, instead they will pay for 50% of the cost of a base metal crown, contributing that smaller amount to the overall cost of the treatment.

At Mint Dental we work very hard to understand all of these details for each patient’s individual treatment plan. This is a huge part of the management of our practice. We usually have to speak with a representative from the insurance company for each and every patient that we see. We are as thorough as possible, so that our patients will have a close estimate of the cost of their treatment. However, it is impossible to be accurate all the time. Many insurance companies will not fully disclose the details of each plan, and they occasionally give us faulty information. This is why it is important for patients to be empowered to understand their own insurance benefits.

Dental insurance can be wonderful- it offers a lot of help to many of our patients. However, another important aspect of our relationship with dental insurance is that at Mint Dental, we do not allow the insurance company to dictate what is appropriate treatment for the patient. We believe that treatment decisions are best made by the doctor and the patient working together, not by a third party payer.

We would be happy to discuss your particular insurance plan. Please feel free to call our office with any questions at 918-346-6016.