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Everything You Need to Know About Dental Insurance

Dental Insurance

Dental treatments are paramount to having a confident smile and improved oral functioning. Sometimes, negligence results in the need for advanced procedures rather than conservative treatment protocols. Regular dental check-ups are helpful for maintaining a healthy oral environment and avoiding the need for major procedures. Plus, good oral health also contributes to your overall health. 

Some people might delay treatment because of the cost factor, but it’s important to realize that few dental procedures will be cheap because of various factors like material cost, the difficulty level of the procedure, the level of precision needed and so on. However, dental insurance has evolved so that everyone can be eligible for dental treatment. These third-party insurance companies have provided various levels of accessibility for the patients, ultimately making sure every citizen is able to have access to dental treatment. 

Things to be considered before choosing a dental insurance plan:

  • Does the dental insurance plan offer you the freedom to choose the dentist, or are you restricted to a limited number of dentists who are chosen by the insurance company? In the latter case, make sure your preferred dentist belongs to the panel member allocated by the insurance company.
  • Which treatments does the plan cover? Does it include investigational or diagnostic procedures, preventive treatment and emergency services? If so, to what extent?
  • Who controls the treatment plan? Do you and your dentist get to decide on the procedures, or does the insurance plan choose? Some insurance plans might require you to follow the “least expensive alternative treatment approach.” Sometimes, you might not want to follow a particular treatment protocol, but you might be forced to because of your dental plan.
  • Are you clear on what the routine treatment plan covers, and how much you need to pay?
  • What are the limitations of the plans? How many times will a procedure be covered under insurance? Does a procedure have its own limit?
  • In case you require a treatment that has been transferred to a specialist, will your plan cover that?
  • Who is eligible under the dental insurance coverage? What is its effective period?

Different types of dental insurance plans:

Deductible

The deductible is a stipulated sum that you must pay towards the cost of treatment before the benefits of the program go into effect. It is also called the “front-end payment,” as you need to pay a sum before your procedure begins. 

Co-insurance or co-payment

Here, you need to pay a percentage of the total cost of the treatment. However, insurance carriers limit the range of health care services covered under this. This is called a “limitation of benefits.” Co-insurance helps keep the premiums down. In this service, both the carrier and the beneficiary are liable for a share of the cost of the dental services provided. For instance, for a dental procedure, if you need to pay 20 percent of the cost of hospital care the remaining 80 percent will be paid by the insurance company. 

In both cases, you would be reimbursed a predetermined percentage of the total amount spent on dental care, regardless of the treatment category. Here, you are free to choose the dentist of your choice. 

Usual, customary and reasonable (UCR ) programs

UCR programs are the most preferred methods of reimbursement for you and your dentist. The American Dental Association has consistently supported the concept of UCR fees. Here also, you have the privilege of choosing your own dentist. Major procedures like orthodontic treatment, crowns and bridges, implant, major examinations, restorative procedures and gum therapy are usually covered under UCR programs. This method has a rate that isn’t more than the dentist’s usual charge, is within the customary range of fees in the locality and is reasonable, considering the circumstances. However, these customary limits may not accurately reflect the fees that the area dentists charge, due to the lack of regulation on how a plan determines the customary fee level.

Table or schedule of allowance

This program determines a list of covered services along with the assigned cost for the particular treatment. Irrespective of how much your dentist charges for that particular treatment, the table of allowance covers only the predetermined amount. The difference between the allowed charge and the dentist’s fee is charged to you. Scheduled allowances do not change automatically as reflection development in community dental prices. On average, plan sponsors did revise schedules of allowance to reflect increases in the price of dental care. 

Incentive payment

To encourage you to seek preventative care, under this method of reimbursement, the percent of dental expenses paid by the plan/insurer increases each year if you are examined by your dentist regularly. This is to motivate you to stay informed about the importance of oral hygiene and to bring awareness about oral care to others as well. Preventive procedures such as dental filling and oral prophylaxis are more likely subjected to incentive schedules than complex treatment like orthodontic procedures and prosthetic works. 

Things to know about dental insurance plans:

Prior authorization of cost

Before starting the procedure, you need to submit the list comprising your diagnosis, the investigation required and the treatment planned to the insurer. These details are given by your dentist. After reviewing, the dental plan administrator may determine whether you are eligible to avail the treatment or not, or to what extent you can claim the amount with your chosen plan. 

Understanding your annual benefit limitations

Your insurance plan may limit you to the number of treatments done per year or will limit the amount that can be claimed per year. Knowing this beforehand would help you to plan your treatment accordingly. You will get an overall idea about what can be claimed and what cannot. More importantly, you can prioritize your treatment, understanding what can be done now versus what can be postponed. 

Likewise, dental insurance coverage is highly flexible, to make sure you and your family members get adequate and necessary dental treatment without paying much out of pocket. Having the right knowledge about insurance details would certainly be helpful for you to be able to take control of your own oral management without any doubts. With the right insurance plan, you’ll be able to receive the proper dental care. 

About the author

Sonal Bhoot, DMD

Dr. Sonal Bhoot has over 15 years of dental experience and received her Doctorate in Dental Medicine (DMD) in 2003 from the New Jersey Dental School. Dr. Bhoot has certifications and proficiencies in cosmetic dentistry, CEREC training, Invisalign, endodontics, oral surgery, TMJ disorders, restorative dentistry, laser treatments and more. She treats the whole family, including children.