Dental insurance is a source of a lot of questions and confusion. Many of the questions surrounding dental insurance stem from the fact that dental insurance often doesn’t work in the same way that our other insurance coverages work. Other insurance types are really the transfer of risk from an individual to a large group. If one of the insured has a large loss (a claim), that claim is paid from the premiums collected from the group. The structure works because claims can be unpredictable. There’s no way of knowing who will have a large claim, so everyone pays into a pool.
How Dental Insurance is Different from Other Insurance
Dental insurance is different than other insurance types because costs are much more predictable than with other types of insurance. If you’re visiting your dentist regularly, your dentist sees you twice a year, plus visits for any additional work you may need to have done. Instead of insuring you against a potential loss of tens or hundreds of thousands of dollars like other types of insurance, your dental insurance is paying toward predictable costs for checkups and mostly routine work. Because dental insurance is paying for predictable costs instead of insuring against large potential losses, many dental insurance plans function much like a discount plan as opposed to covering the entire cost.
Dental Insurance Usually Covers a Percentage of Your Procedure Cost
Most people with insurance coverage get their coverage through their employer. The employer purchases a plan from a selection of dental insurance plans offered by an insurance company or broker. The percentage paid for procedures covered by that plan depends largely on how much money the employer spends on the plan they’ve selected for employees. Coverage of 50 percent to 80 percent of the procedure cost are common, with most dental insurance plan coverage falling into this range. Generally, if the employer or union purchases a more expensive plan as a benefit for their employees, that dental insurance plan will cover a higher percentage of the cost of procedures and provide coverage for a wider range of procedures. These plans make the employee responsible to pay whatever amounts aren’t covered by their dental insurance.
Deductibles, Copayments and Caps
Dental insurance is similar to other types of insurance in the areas of deductibles and copayments. Deductibles for dental insurance are typically an annual amount, and the insurance company will cover procedures after your deductible has been met. If, for example, your plan has a $500 deductible, the insurance company will pay a percentage of the cost after you have paid $500 in that year. This yearly period is called a benefit period, and it might not match the calendar year.
Some dental insurance plans use a fixed copayment schedule for certain covered procedures. A copayment is a payment you make toward your dental care, and a fixed copayment means your copayment is a fixed dollar amount as opposed to a percentage.
Many dental insurance plans have a cap which limits the total amount that the particular plan will pay toward your dental care within a benefit period. By placing a cap on coverage, the dental insurance companies can offer more competitive pricing for plans sold to employers or unions because they know how much they will pay out as a maximum amount per patient.
In-Network vs. Out-of-Network Coverage
Some dental plans use a network of preferred providers but offer limited coverage for visits to dentists outside of the network. Visits or dental work performed by out-of-network dentists often aren’t covered at the same percentage or with the same copayment as with in-network dentists. This means that your out-of-pocket costs might be higher with an out-of-network dentist. There may also be limits on the types of procedures covered by out-of-network dentists.
We will gladly submit accurate billing to ensure that you receive the maximum amount of coverage provided by your dental plan. In submitting accurate billing to your dental insurance company, we cannot:
- Alter the date of treatment for any reason;
- Submit a claim for a higher amount than the actual fee charged;
- Submit a claim for any procedures we have not performed.
While your dental insurance might not pay the entire cost of your dental work or visits, insurance companies can’t govern the quality of your care. Your dental care is always based on decisions made between you and your dentist.