How to Understand and Maximize Your Dental Insurance Coverage for the Year

November 27, 2018

Dental insurance coverage

Video Transcript:

Kelly (Financial Coordinator): For our new patients, we do appreciate when they bring their dental insurance information for us. It helps us prepare, if there are any treatment needs, we’re able to look that up or help them understand their coverage.

Shana (Patient Coordinator): Insurance typically covers routine cleanings, exams, and a portion of other procedures.

Kelly: Currently, we are in network with Delta Dental. That means that we are a preferred provider. Therefore, there may be some contractual discounts or may be some services may be a little more affordable for some patients.

Shana: A deductible would be something that insurance requires you to satisfy prior to certain dental procedures.

Kelly: A lot of people think that just because we are out-of-network, they’re unable to come to our office. However, that is just a myth. Most insurances do offer out of network coverage and it just may be a difference of percentages or coverage levels of different services with our office.

Shana: I would recommend patients take full advantage of their insurance and know their insurance policy so they know when they can be seen and at what extent they can be seen for. 

Understanding Insurance

Understanding your dental benefits may not be as easy you think. There are many factors that go into insurance. It’s extremely important to first know and understand your dental insurance coverage to better benefit you.

Typical dental insurance coverage

According to the National Association of Dental Plans (NADP), roughly 77% or 249.1 million Americans have some form of dental insurance. This may be through your employer or through other group programs. A dental benefit plan is set up to cover certain costs. The dental plan may cover some procedures fully, it may cover a percentage on other procedures, and you may find that some recommended procedures are not covered at all.

According to Consumer Reports, the most common dental plan coverage through your employer is a 100/80/50 plan [meaning]:

  • Diagnostic and preventative procedures are covered at 100%. This would include cleanings, exams, and films. Typically, cleanings and exams are covered twice per benefit year.
  • Basic procedures are covered at 80%. This would include fillings, simple extractions, and some periodontal work. These may be subjected to waiting periods, frequency limitations and or deductibles.
  • Major procedures are covered at 50%. This would include difficult procedures such as crowns or bridges. These may be subjected to waiting periods, frequency limitations, and or deductibles.

Although this is typical dental insurance coverage, we urge all our patients to contact their human resources department or their insurance provider to better explain your dental benefits to you.

Here at Govani Dental, LLC, we try our best to be as transparent as possible. We send out pre-treatment estimates to insurance for basic and major procedures recommended for each patient. This allows the patient to be aware of what their probable copay would be (if any) prior to their scheduled treatment. We do this as a way to promote an honest and healthy patient-provider relationship.

Please note that this out of pocket cost may be subject to change

Frequency and limitations

Each dental benefit plan is unique and coverage may vary based on the plan itself. Some plans have frequency and limitations. There are three main areas we should look at to fully understand the limitations of typical insurance coverage:

Waiting periods

Many individuals are not aware that dental plans may impose a waiting period. This is the subject amount of time before you receive full coverage on certain procedures such as crowns or bridges.

There is likely no imposed waiting period by your insurance provider for preventative care such as exams, cleanings, and x-rays.

Maximums

Your insurance plan is allotted a maximum amount per patient per year. That is the maximum amount of benefits insurance will spend within a given plan year. This is annually and is typically from January to December. However, this does vary based on each insurance policy. Here are a few things to consider when reviewing your insurance maximum:

  • If there’s any leftover amount from your annual maximum, you will lose this amount at the start of each benefit year. Be sure to take advantage of your maximum annually. If you don’t use it, you lose it.
  • The policy holder, spouse, and any dependents on your dental plan will have their own dental benefits to utilize throughout the year.

Deductibles

A deductible is the amount an individual must pay out of pocket before the dental plan will pick up the subjected dental services. The deductible amount does vary, however, for most dental plans it is $50 for an individual and $150 for a family.

This deductible renews at the beginning of every benefit year. Take advantage that you already paid your plans deductible for the year and look into making an appointment before the year ends.

In network vs. out of network – What is the difference?

If a provider is considered to be in network with your insurance plan, the provider has agreed to accept the insurance carriers approved fee for service.

For example: If a provider charges $100 for a service and the insurance carriers approved amount is $75. As a member you would save $25.

If a provider is considered to be out of network with your insurance plan, you will be responsible for the difference between the providers full charge and your insurance plans approved amount.

For example: If a provider charges $100 for a service and the insurance carriers approved amount is $75. You would be responsible for the remaining $25.

At Govani Dental, LLC, we are a preferred provider with Delta Dental. If you do not have Delta Dental insurance, we would be more than happy to submit your claim to another insurance company.

Frequency of dental visits? How often should I be going to the dentist?

We encourage all our patients to be seen on 6-month intervals for exams with our trusted doctors. However, how often we request to see you depends on your overall oral health and is ultimately at your providers discretion. If it’s been longer than 6 months – now is the time to utilize your dental insurance coverage for the year.

Why are exams and general cleanings requested at 6-month intervals?

Exams and general cleanings allow us to see any changes in your overall oral health such as:

  • Changes to stable and healthy tissues
  • Cleaning off plaque and tartar build up
  • Prevention of gum disease and gingivitis
  • Oral cancer screenings

Why do we need x-rays?

X-rays allow us to see any changes in your overall oral health that we visibly may not be able to see during your routine exam such as:

  • Checking for new decay between teeth
  • Bone loss
  • Abscesses below the gum
  • Revealing changes in bone or root health
  • Rule out pathology
  • To better assist in dental procedures – to ensure that areas of treatment are healing properly

Knowing your benefits

We strongly encourage all our patients to contact their insurance provider or human resources department, in order to better explain your benefits to you. The insurance contact number is generally located on the back of each insurance card. Please contact your human resources department if you have yet to receive a copy of your insurance card from your employer.

Taking action early

Be sure to act early and make an appointment today to maximize your remaining dental insurance coverage for the year to prevent any recommended treatment from getting worse. In fact, it is easier to treat small problems now than allowing them to worsen, in turn saving you time and money.

If you haven’t seen the dentist regularly, take advantage of our early morning or late evening hours. Interested in scheduling your first visit with us? Easily book an appointment online or call the office at 920-231-1955.

Ready to Join the Govani Dental Family?

If you’re interested in becoming a Govani Dental patient, schedule your appointment online or by calling 920-231-1955.

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