What is Dental Insurance?
A great misconception is that dental insurance is actual insurance. It is not! Dental insurance is a benefit program that is agreed upon by the insurance company, you and your employer. The benefits have service limitations, caps, waiting periods, procedure exclusions, downgrades and yearly maximum payouts. Almost all insurance plans have the patient pay nothing or very little for the insurance. The employer picks up all or most of the plan. The dental insurance is a benefits package the company offers to employees. It is almost always a losing situation for patients to buy their own dental insurance. True insurance is meant to cover the expenses of unexpected incidences, not routine events for which you can plan. Dental insurance, on the other hand, offers more coverage for routine services (exams and cleanings) and little coverage for major treatment.
Dental insurances make money by taking in more money than they pay out. Therefore, they write policies in their favor to limit their losses.
1) There are MANY different types of policies out there!
There are a lot of choices when it comes to Dental Insurance, and what type of policy you or your employer has chosen will determine where you can go and whom you can see. The most common types of dental insurance are:
DHMO (Dental Health Management Organization): This type of policy mandates that you must use your insurance carrier’s contracted network of dentists. While often the most affordable, it is the most limiting of the different policy types. These dentists that accept this type of insurance generally are working for corporate dental practices. These are insurance mill type clinics that have revolving dentists. The dentist at these clinics do not stay long term. My office does not take DHMO insurance.
PPO (Preferred Provider Organization): This popular plan that allows the patient to see doctors in or out of network with set percentages for each type of provider.
Insurance companies will usually break your coverage down into four major categories:
Preventative: This will include services like x-rays, cleanings and exams.
Basic: Fillings, root canals and periodontal cleanings (dealing with your gums and bone).
Major: Crowns, bridges, dentures and other large procedures.
Orthodontics: Insurance carriers may add orthodontic coverage to their policies. Usually this is limited to children.
Each category will be covered at a different percentage by your specific policy. There may be a deductible. Furthermore, there will be downgrades in coverage. What this means is if there are multiple options to fix a dental condition, insurances will not pay for the best or most common treatment but will pay a percentage of the least expensive option.
There are a few other key features of dental insurance. They are:
Waiting Periods: Some policies will mandate waiting periods. The insurance companies don’t want you to have a problem and then sign up for insurance to fix that problem. Insurance companies want to reduce the amount of benefits they pay out in order to make more money. These waiting periods are usually one year.
Missing Tooth Clause: Some plans will provide benefits for teeth you’ve lost before you had the policy or not. This is called the missing tooth clause. In our experience, most plans have a missing tooth clause. Insurances again do not want to pay for a pre-existing problem. They want to limit the benefits paid out. Some plans will put a missing tooth clause in effect for up to five years thus creating a specific kind of waiting period.
Preventive Frequencies: Most plans will limit the number of times you can receive preventative services within your benefit year (which may be different from a calendar year!). Normally cleanings and exams are allowed either twice a year or once every 6 months. These are not the same! One allows the cleanings to be anywhere in the year where the other dictates how far apart they must be. The insurance companies hope there is a scheduling error. If you are one day early in your insurance policies guidelines the insurance companies will not pay.
Out of Network Benefits: Our office takes any insurance where YOU the patient can decide what doctor is best for you. We are out of network on all insurances. The limitations in type and quality of dentistry that is regulated by being an in-network dentist would not allow my practice to deliver the award winning dentistry we are known for. As a general rule, our offices sees out of network benefits that equally match in network for preventative services, and match or cost only 5 – 10% more for more major work. This minor difference in what your policy pays is nothing compared to the freedom of YOU choosing your own doctors instead of picking a random doctor from a list.
Why Does Dr. Nugent’s Office Not Know Exactly How My Benefits Work?
Many patients seem amazed when they tell us they have Delta Dental, for example, that we don’t instantly know exactly what their plan covers. Regrettably, the sheer number of dental plans, and the hundreds of constraints set per plan, it is IMPOSSIBLE to know exactly what your plan will cover for each dental procedure.
For example, in our Pasadena dental office we have about 100 different Delta Dental insurance companies we deal with listed in our database. Furthermore, these Delta plans operate independently of each other with different addresses and phone numbers. Within these 100 different Delta Dental Insurance companies, there are hundreds of different insurance plans that each offer different yearly maximums, co-pays, restrictions, deductibles, and frequencies.
Thus, even with a particular insurance company, such as Delta Dental, there are thousands of different individual plans and knowing the exact ins and outs of all of these plans is impossible. Dr. Nugent pays two outside companies to help research your dental benefits. Plus, our front desk tries to call your insurance company to get better breakdowns on your policy. Regrettably, it can take up to forty-five minutes to get a human to pick up the phone in a call center. Even when we do talk to a representative, we sometimes will not get exact benefits breakdowns from your insurance company. Therefore, we cannot always be 100% accurate on your dental benefit estimation. On all our paperwork it is clearly marked that insurance payment is an estimate and that you are responsible for any balance left after insurance payment.
How Does Dental Insurance Work?
While all dental plans are different, the standard model for dental insurance is for the plan to have a yearly maximum, a deductible and to cover certain services at set percentages. Once a patient has hit their maximum reimbursement, dental insurance will not pay for any more treatment that may be needed for the year. Again, dental insurance is not real insurance. Can you imagine if you get into an auto accident and the insurance company will only pay a certain of money per year until your car is fully repaired. The majority of dental plans have a benefit schedule similar to this:
Yearly Maximum/Deductible Covered Percentages
Maximum Preventative Basic Major
$1,000.00 100% 80% 50%
Why are Some Dental Procedures Not Covered by My Plan?
If your find that certain dental procedures are not covered on your dental plan it is because your employer purchased a plan that has restrictions on services covered. The more restrictions and limitations on a plan, the less expensive the plan is to purchase for your employer.
What is a Yearly Maximum?
A yearly maximum is a set dollar amount that a dental insurance company will pay out in a year. Most maximums run on a calendar year beginning January 1 and ending December 31. However, some run on a fiscal year. It is usually the entity purchasing the insurance who determines if they want the insurance plan to be run on a calendar or fiscal year.
Why Hasn’t Coverage on Dental Insurance Increased in the Last 40 Years?
Dental insurance became available in 1954. It is surprising to learn that the yearly maximum benefits on these early plans were 1,000 dollars. This maximum benefit is what most plans have in place today. If dental insurance had kept pace with inflation, the yearly maximum today would be around 5,500 dollars! Of course dental insurance premiums have increased every year since 1954, but the maximums the insurance companies will pay have not. Insurance companies keep raising premiums without paying out more for coverage. Thus, more profits for the dental insurance companies. Medical insurance can look at multiple factors to determine your insurance cost: family history of disease, cholesterol levels, blood pressure, weight, smoking history and past health care problems. Medical insurance companies have teams of statisticians that know the chance of you getting ill and needing to use your medical insurance. Therefore, they can charge more based on the risk of you needing medical insurance. However, there is no way to calculate the chance of someone needing major dental work so dental insurance have limited the polices to a maximum payout per year. This limits the financial liability of dental insurance companies all while they continue to raise costs.
Also of note, maximums will automatically renew each year and almost NEVER roll over from year to year. In other words, if you do not use your entire yearly maximum, you lose it.
What is a Deductible?
A deductible is a set amount that the insured must pay before a dental insurance company will pay out any dental benefits. Some dental plans waive the deductible for preventative procedures. This means you do not have to pay your deductible before the plan will pay for routine services, such as cleanings and examinations. However, it important to know if your plan waives the deductible for preventative services so you are not surprised to find you owe money for a cleaning or exam.
How are Dental Coverages Broken Down?
While all dental insurances are different, most insurance companies consider:
Major: dentures, crowns, implants, bridges and partials
Basic: fillings, simple extractions and root canals
Preventative: routine cleanings, comprehensive and preventative examinations and standard x-rays
Explain a “Missing Tooth Clause”?
Almost all dental insurance plans carry a “missing tooth clause.” A missing tooth clause protects the insurance company from paying for the replacement of a tooth that was missing before the policy was in effect. Thus, if you lost a tooth before you had your dental insurance coverage and then decided you wanted to replace the tooth with a partial, bridge or implant. Your insurance company would deny to pay for any services to replace a tooth. Your insurance company may also have a restriction stating they won’t pay to replace a partial, bridge or crown that you had placed prior to having your particular insurance or simply not pay to replace it before a specified time limit has passed. The missing tooth clause is another way insurance companies can limit the amount of money they pay out.
What Does My Insurance Downgrade White Fillings to Metal Amalgams?
Dental insurance plans will downgrade white fillings to silver amalgam fillings when they pay their portion of fillings.
There are two main types of fillings: 1.) tooth-colored composite fillings that are made of a resin material and 2.) silver-colored amalgam fillings that are made with a combination of mercury and other metals. Amalgam fillings are cheaper than composite fillings and require less of a dentist’s time to complete. Therefore, amalgams are less expensive than composite fillings. Dental insurance companies usually will pay for procedures based on what is called the Least Expensive Alternative Treatment (LEAT). Insurances don’t care if there is a better and more cosmetic solution to fix your dental problems. Insurance only cares about paying out the least amount of money. Imagine your house receiving damage from a hurricane. A contractor wants to repair your brick wall with bricks that match the rest of your house. However, if your homeowner’s insurance uses the LEAT principle and they will only pay for a log cabin wall. In order for you to have the better wall replaced you are forced to pay the difference between a brick wall and a wooden wall. Dental insurance is not real insurance.
What Are Some Restrictions That Dental Insurance Companies Impose?
After dealing with hundreds of different insurance plans, our Pasadena office see the same restrictions over and over. These are:
- Least Expensive Alternative Treatment clauses
- Waiting periods for treatment
- Missing Tooth Clauses
- Downgrading cosmetic white fillings to silver amalgam fillings
- No coverage for dental implants
- Limiting the number of cleanings a patient that has who has periodontal disease can have per year
- Age limitations for treatment: orthodontics, sealants and fluoride
- Frequency limitations on preventative treatment
Do My Dental Benefits Roll Over Every Year?
No, very simply put if you “don’t use it you lose it.” Benefits do not rollover. Most dental insurance plans have a yearly maximum of $1,000. If you have not visited a dentist in your plan year or have not utilized all of your yearly maximum, it will go away.
What is Usual, Customary and Reasonable (UCR)?
A difficult aspect of dental insurance is trying explain to our patients the concept of Usual, Customary and Reasonable (UCR.) Many insurance plans pay their benefits based on UCR fees, not the dentist’s actual fees. The insurance companies try to define the narrative of what a procedure should cost. The insurance companies imply that the UCR fees that they set are the average fee being charged by dentists in the area. However, the insurances arbitrarily make up the UCR limits and offer different levels of UCR fees from which employers can choose. For cost savings, employers often choose the lowest UCR policies because it saves the company money and the company can still provide dental benefits.