One of the biggest questions we get asked at Cochecho Dental is “Will my insurance cover that?” Dental insurance plans help patients budget for the cost of maintaining a great smile but how does it work? Although all dental plans are different and have different features, most plans are standard with their outline of coverage. Delta Dental has a quick overview of how most dental plans work.
Dental insurance and health insurance plans are very different from each other. Most dental benefit plans are simple and specific regarding what procedures are covered and what the out-of-pocket expenses are but to get the most from your benefits, it’s important to understand your individual policy. Let’s jump into the basics.
Waiting Periods: Most dental plans have waiting periods ranging from 3-12 months that must be met before dental treatment can be covered. Major treatment can sometimes have a waiting period of up to 2 years after the policy has started.
Annual Maximum: The total amount an insurance company will pay in an individual’s dental plan per year. The benefit year can be calendar (January to December) or run on a specific benefit period such as April-March or July-June. Coverage maximums usually range from $750 up to $35,000. Once the yearly maximum has been reached, the patient is responsible for 100% of the remaining dental procedure cost for the remainder of the benefit period. When the benefit period renews, the annual maximum becomes available again.
Deductible: An insurance deductible is the amount that must be paid before most dental procedures are considered to be covered. A deductible does not usually apply to preventative and diagnostic services but in some cases it may, depending on the individual plan selected. Deductibles can range from $25-$200 and usually re-set with the annual maximum when the benefit period renews.
Co-Insurance: Co-insurance is the amount the patient is responsible for that the insurance does not pay. The annual maximum benefit is paid out in percentages based on the dental procedure being done. Dental treatment is grouped into 3 categories of coverage: Preventative/Diagnostic, Basic, and Major.
Most plans cover 100% of preventative/diagnostic services which include cleanings, x-rays, exams.
Basic treatment is typically paid by insurance (once the deductible has been satisfied) at 80%. Basic services include fillings, treatment for gum disease (periodontal services), extractions, and root canals.
Major treatment such as crowns, bridges, implants, oral surgery, and dentures are typically paid by insurance at 50% (after deductible satisfied) with the patient being responsible for the remaining 50% of the procedure cost.
Every policy differs in how procedures are categorized as preventative, basic, and major so it’s very important to understand what is covered when considering different plans. For example, some policies may consider gum disease treatment to be preventative or basic and changes the amount the patient may have to pay out-of-pocket.
Frequencies and Limitations: Dental plans are intended to assist patients with financial obligations for dental treatment so you may not be covered for every dental need. Most plans limit the number of procedures you can have or how often it can be done. For example, most dental benefits allow a cleaning twice per year, or once every 6 months. In certain dental plans, if they only allow cleanings once in 6 months and you visit your dentist 1 day early, the cleaning will be denied. Some insurance companies may also deny certain services, even if they are recommended by your dentist. It is highly recommended you review the plan’s limitations before settling on a plan. The ADA (American Dental Association) explains how “Alternate benefit” exclusions may also be applied. This means, if you have a white (composite) filling done on a back tooth that doesn’t show in your smile line, your insurance plan may pay for an alternate benefit of a silver (amalgam) filling instead, resulting in an extra out of cost expense to the patient.
At Cochecho Dental we work hard to understand our patients’ dental benefit plans. We offer a complimentary benefit breakdown for each patient to assist with planning for future treatment. It is often impossible to know exactly what every plan pays on every procedure so we provide treatment plan estimates based on the information we are able to gather about your dental plan. For more information, visit our Cochecho Dental website!