How Dental Insurance Work

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    Step 1: Tell Us What Kind of Dental Care You Need

    Last Step: Contact Information

    How does dental insurance work?

    Dental care can be very expensive, so dental insurance is very helpful in reducing the out of pocket cost of dental treatment.  Dental insurance covers all, or a portion of dental services.  Most plans have an annual maximum coverage amount and an annual deductible.  On average, annual maximums may range from $1000 to $2500. Annual deductibles may range from $25 to $100 per family member.  No matter which plan you choose, services fall under one of three categories: Preventative, Basic, and Major.  The percentage of coverage for each category is different.  Preventative services are covered at the highest percentage, while major services are covered at the lowest percentage.

    What types of dental insurance are available?

    Each dental insurance carrier has a variety of insurance plans to choose from.  Some plans cover only preventative services. The majority of dental plans offer comprehensive coverage.  Comprehensive coverage includes all three categories; preventative, basic, and major.  Preventative services are covered at the highest percentage, while major services are covered at the lowest percentage.

    What does dental insurance cover?

    Preventative:  Preventative services may include routine cleanings, exams, x-rays, fluoride treatments, and sealants.  Most dental insurance plans cover preventative treatment at 80% to 100%.

    Basic:  Basic services may include amalgam fillings, composite fillings, extractions, root canal therapy, and deep cleanings. Many dental insurance plans cover basic treatment at 60% to 90%.

    Major:  Major services may include crowns, onlays, bridges, dentures, partial dentures, oral surgery and implants.  Most dental insurance plans cover major services at 50%.  In the past, very few dental insurance companies covered dental implants, but now implant coverage is frequently included as a covered benefit on many dental insurance plans.

    Orthodontic Coverage:  Some insurance plans offer orthodontic coverage.  Orthodontic coverage is usually 50% but can vary by plan.

    Waiting Period, Missing Tooth Clause, Age Limit, and Frequency Limitations

    When comparing insurance company plans, some phrases to pay attention to are:  waiting period, missing tooth clause, age limit, and frequency limit.

    Waiting Period:  Some dental insurance plans have waiting periods for basic and or major services. This can be especially true with individual plans that are purchased directly from the insurance company and not through an employer.  Waiting periods are typically 6 months for basic services and 6 to 12 months for major services.

    Missing Tooth Clause:  If a dental insurance policy has a missing tooth clause, tooth replacement will only be covered if a tooth was extracted or lost while the policy was active.  If a tooth was extracted during a period where a patient had no insurance or was covered by a different insurance company, an implant, partial denture, or bridge would not be paid for by the new plan.

    Age Limit:  Many dental insurance companies have age limits on fluoride treatments, sealants, and orthodontic treatment.

    Frequency Limit: When it comes to replacing existing restorations such as fillings and crowns, most dental insurance companies limit how frequently they will pay for a replacement.  Dentures, cleanings, x-rays, and exams also have frequency limits.  The time period varies by plan.

    Who Are The Top 5 Dental Insurance Carriers?

    There are many dental insurance companies.  The major carriers include: Delta Dental, Cigna, Humana, Aetna, Metlife, United Healthcare, United Concordia, Ameritas, Anthem Blue Cross Blue Shield, GEHA, Assurant, and Guardian.  The coverage details outlined above apply to all of the major carriers. Determining which carriers are the best would depend on your coverage needs, and the plans available to you.

    What type of plans does each carrier offer?

    Each carrier has many plan options to choose from.  They vary by premium cost, annual maximum coverage, deductibles and coverage percentage.  It is important to note that more than likely only certain plans will be available to you.  If you are in an employer sponsored group plan, your employer will determine which companies and plans their employees may choose from.  If you are purchasing an individual plan directly from an insurance company, during the application process you will be required to provide your zip code and county of residence.  You will then be told whether or not the insurance company is selling individual dental insurance plans in your area.

    In Network Coverage

    Choosing an in-network dental provider is the best way to maximize your insurance coverage.  These providers have agreed to charge the fees set by the insurance company.  These fees are usually much lower than the fees charged to cash paying patients.  When contacting the dental office, don’t ask “Do you take my insurance?”  Most dental offices will bill any insurance company for their patients, but if they are not in network with your plan this can result in hundreds of dollars of extra out of pocket cost. The correct question to ask is “Are you an in-network provider for my insurance?”  A list of in-network dental providers may also be obtained from the dental insurance company.

    What is required to join?

    You will have to fill out an application before purchasing dental insurance, but it is unlikely that it would be denied.  You may be asked if you are a smoker and when you last had dental insurance coverage. These questions may be used to determine whether or not a waiting period for basic and major services is required.

    Are there alternatives to dental insurance?

    Compared to medical insurance, dental insurance is relatively inexpensive.  Dental insurance  plans may be purchased for around $40 a month or less.

    • Cigna Individual Plans:
      • $21 a month for preventative only coverage at 100%
      • $35 a month for preventative coverage at 100%, basic at 80%, and major at 50%, with a $50 deductible and a $1,000 a year maximum
      • $40 a month for preventative coverage at 100%, basic at 80%, and major at 50%, with a $50 deductible and a $1,500 a year maximum (includes $1,000 in additional orthodontic coverage at 50% with no age limit)
    • Metlife Individual Plans:
      • $33.62 a month for preventative coverage at 100%, basic at 70%, and major at 50% with a $75 deductible and a $1000 annual maximum (includes 50% implant coverage)
      • $37.05 a month for preventive coverage at 100%, basic at 70%, and major at 50% with a $50 deductible and a $1500 annual maximum (includes 50% implant coverage)
      • $42.36 a month for preventative coverage at 100%, basic at 80%, and major at 50% with a $25 deductible and a $2000 annual maximum (includes 50% implant coverage)

    Simply receiving preventative care (cleanings and examinations) twice a year may cover the annual premium cost when compared to paying cash for these services.  Some insurance companies offer discount savings cards, such as Vital Savings by Aetna.   Discount plans and cards are very inexpensive.   The Vital Savings dental card can be purchased for $7.99 a month. After you purchase the card or plan, you would receive discounted rates at participating dental offices.  Before purchasing a discount card or plan, it is important to make sure that there are dental providers in your area that will accept it.

    Some dental offices offer in-house discount plans.  They typically require an annual fee that entitles a patient to discounts on dental care. These types of plans frequently result in higher treatment cost for patients when compared to paying for dental insurance and receiving treatment from an in-network dentist. Example:

    • A crown done at an in-network dental office for the contracted amount of $900 that is covered at 50% would cost a patient $450.
    • The non-contracted cash price for the same crown is frequently as much as $1200 to$1600. The in-house discount percentage would normally be between 5% and 20% of that fee which would cost a patient considerably more than $450.

    Many patients who require extensive treatment choose to spread their treatment out over multiple years.  Once they reach their annual maximum allowance, they will sometimes wait until their policy renews to continue treatment.  They may choose to have their teeth cleaned and cavities treated first, and schedule major treatment such as implants and crowns last.

    It is very important when shopping for dental insurance to read the coverage information carefully. Although dental offices may file your dental claims for you, it is not their responsibility to know every detail of every insurance plan.  Ultimately you will be responsible for any cost not covered by your insurance.


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