Did The New Year Bring You New Dental Insurance?

It’s a new year, and your dental insurance may have changed. What does this mean for you? Let’s look at two of the most frequent questions about dental insurance.

Do you take my insurance?” It is important to identify what type of dental plan you have. Traditional (or indemnity) plans are the least restrictive. They allow you to see any dentist you choose and will pay your benefits to any licensed dental office.

With PPO (Preferred Provider Organization) insurance plans, you can visit any dentist you choose, but you may pay less out of your pocket if you see a dentist who is on their provider list. (Sometimes called a participating provider.) This is because the insurance company contracts with those dentists to accept a pre-set fee schedule, which is often less than the dentist’s usual fees.

DMO (Dental Maintenance Organization) insurances assign you to a dental office. Your assigned office is the gatekeeper, similar to the HMO model in medicine. Benefits are only paid if you go to your assigned office or if that office refers you to a specialist who is also within the DMO network.  If you want to change your dental office, you must call the DMO company or speak with HR at your employer to have them change your assigned office before you go to the new office.

Discount Dental Plans (DDP) are not really insurance, but many participants think of them as insurance. Dentists contract with these plans to accept a discounted fee schedule. You pay the plan a fee to enroll. The plan does not pay your dentist, you pay the dentist the amount indicated on the discounted fee schedule on the day you have the services performed. For some people, these are a great option as they save more than what they paid for the enrollment fee. Others may find that they spend more on the enrollment than they are saving.

“Why won’t my insurance pay for this?” It is important to remember that dental insurance is designed to help you pay for your care, but it was never meant to cover everything you might need, particularly if you have not been to the dentist in a long while. Each benefit period has a maximum payout amount. Once that maximum is reached, the insurance will not pay again until a new benefit period starts.  For most insurances, the maximum payout has not changed in over ten years! Treatment for just one infected tooth can put you close to or over your maximum  If you stop dental treatment when your insurance benefits run out, you may find your self in a dangerous spiral of needing expensive treatment each year.

Most insurance plans have exclusions and limits. If you have insurance through your workplace, your employer chooses the plan and what it covers. Some common ones are:

Frequency Limitations:  Most plans limit how often they will pay for specific services. Generally speaking, the more expensive the dental service, the longer the waiting period between payments.  Preventive care such as your cleanings might be paid twice a year or every six months, but your cap or crown might only be paid once every 5 or 10  years.

Cosmetics: Dental insurance is designed to pay for treatments for problems that will cause serious consequences like gum disease or tooth decay. By definition, cosmetic procedures are ones done to improve your looks. While looks are important, they are not the same as disease and do not threaten your health if left untreated.

Experimental Procedures: Most insurance companies are slow to embrace new treatments and technologies. If you want the newest treatment, you may find that you have to pay for it yourself. In most cases, procedures that are shown to be effective over time will eventually become covered treatments. Dental implants are one example of this.

Missing Tooth Clauses: Some plans exclude replacing teeth that were removed before you had this particular insurance. This includes teeth that never formed, called congenitally missing teeth.

Coordination of Benefits/Non-Duplication of Benefits: If you are lucky enough to have more than one dental insurance plan that covers your treatment, you would probably think that the second plan should pay most or all of what the first one doesn’t. In many cases that is true. But there are some plans that have a non-duplication clause that specifies the maximum it will pay for each service. If your first insurance pays that amount or more, your second insurance will not pay anything additional.

Dental insurance can be quite confusing. Each plan is unique. If you would like to see how you can best use your dental insurance at my office, please call us at 440-960-1940.