At least once a week I hear the phrase “I only want what my insurance covers.” While I can certainly understand the desire to use the dental insurance that you have, doing only what your dental insurance covers is not always the best option. The dental treatment you decide to do should be decided between you and your dentist based on your mouth and your situation. Do not allow a dental insurance company to dictate what is right for you. (They will try to do so by denying treatment that you need or by saying you didn’t submit a pre-determination to them. You’re not legally required to submit one.) You should choose the treatment that is the best for you regardless of your dental insurance coverage.
What you need to understand is that your dental insurance is not meant to cover all of your dental fees. It’s supposed to be an aid to affording your dental care. The maximum annual payout amount for dental insurance has remained the same (usually $1000) for many years. Only in the past few years have we seen some companies start inching the amount up to between $1500 and $2000. These days, a single severely broken down tooth could eat up all that $1000 (or even $2000!) quite easily.
There are other aspects to your dental insurance also.
- Most dental insurances have an annual maximum that they will pay. This is the most dollars that they will pay out in any benefit period (for most this is a calendar year, but some insurances do have a different benefit year period). Once they've paid that maximum, they will not pay any more until the benfefit period renews. So even if you think you get "two free cleanings a year" if your insurance has already paid out it's maximum amount for that year, the 100% coverage for preventive services that you count on (and makes it what you call "free") is invalid and you will have to pay for those service out of your own pocket.
- Be sure to find out your annual deductible (what you have to pay before your insurance kicks in). For many insurances, your cleanings fall outside of the deductible (though some policies apply the deductible to any dental service). In most cases, any other dental treatment will be subject to the deductible, so you will have to pay that amount in addition to your copayment.
- Copayments: Dental insurance companies divide dental services into categories and pay different percentages on different categories. The percent that they do not pay is called your copayment. You cannot rely on the percentages that the insurance company publishes. Most insurances will use a UCR (UCR=usual, customary, reasonable) to calculate their plans. The insurance companies survey a geographic area to find the average fee and then take 90% of that average to create their UCR rate. (Remember that discount clinics are included in the survey and their fees bring down the overall average.) Therefore, almost every private practice dentist will have fees over the UCR. Insurance companies would rather say the dentist’s fees are above the UCR than say that their benefits are low. This is especially important if you are using the services of a dentist who does not participate with your plan or if your plan is a traditional one which allows you to go to any dental office since in those cases you will be fully responsible for the portion that your insurance company does not pay.
- Limitations/exclusions to your policy: your plan may not cover certain procedures (exclusions) or limit how often it will pay for certain procedures (limitations or frequency limits) or limit when it will cover certain procedures (limitations). For example, many plans exclude cosmetic procedures such as teeth whitening or veneers. Many plans will only pay for crowns or dentures once every 5 years (so if you lose your denture that's 3 years old, your insurance will not pay for it again for 2 more years!). Your plan may say it will cover 2 cleanings a year or 1 every 6 months--there's a difference! with the first option, you could have a cleaning in January and again in February and both would be paid. With the second option, you'd have to have your second cleaning 6 months + 1 day after the first if you want your dental insurance to pay for it. A dental insurance might also say that you can't have a periodontal maintenance cleaning unless you've had scaling and root planing ("deep cleaning") or surgical gum treatments.
- Also remember as new procedures emerge, they are often considered “experimental” by insurance companies. It can be hard to get this designation changed even though the procedure becomes more routine and more reliable. (Dental Implants are a good example of this.)
Remember, insurance companies are a for-profit business. This may mean that what they cover is not the best choice for you.
If you need help understanding your dental benefits, ask at your dental office. I know we are glad to help our patients try to understand their dental benefits and get the maximum use from it.
*Note: The information in this article is not meant to replace the clinical judgement of your health care professionals.
Dr. Jennifer Robb is a private practice dentist who sees both children and adults in her general dentistry practice.
1320 Cooper Foster Park Rd.
Lorain, OH 44053