Do you feel your dental insurance does not adequately cover today’s dental needs?
Dental Insurance plans were designed in the 1970s.
25 years later, many plans still have the same ($1000) maximum.
I am not against having dental insurance. If your employer has paid for you to have this benefit – kudos to your employer. It is very nice to have benefits to supplement taking care of your dental health. Employers can usually get better coverage for the dollar because they will purchase a group plan for the whole company.
What to look for when buying dental insurance?
Not all Dental Plans are the same. Dental plans will vary in their coverage. The same insurance company will offer different plans, and they will have different reimbursement benefits. It is not necessarily which dental insurance company is the “best” but rather which plan was chosen. Coverage and benefits depend on which policy you or your employer chooses.
Our example here shows the reimbursement for a dental cleaning.
Everything about the service provided is the same.
- Same Insurance Company
- Same Dental Office
- Same Dental Procedure
- Same Fee/Cost
- Same Month (that the dental procedure was provided)
- Same 100% coverage (per Insurance Plan)
Q: So what is different Dental Insurance Benefit coverage?
A: The 100% benefit coverage changes when it comes down to the dollar amount they pay out!
Why does the Dental Insurance coverage change?
The Dental Insurance Company changes their “Covered Expense” amount (also known as “Amount Allowed” or “Usual, Customary & Reasonable” or “UCR”) each time.
Dental Insurance might lead one to believe that the “Amount Allowed” is a customary and reasonable fee charged for that service in that geographic area. That implies that the same Insurance Company should have only ONE fee amount for that ONE service.
In our example, the same insurance company changes what they consider to be the usual and customary fee. They will provide 100% of benefits for a cleaning. That does not add up to 100% of the dollar fee. The 100% is on their “Covered Amount Allowed” in dollars and that changes each time.
Some people, they might get 100% covered in dental benefits, according to the plan. But not everyone will, even though they all have the same dental insurance company providing dental benefits to the tune of 100% on cleanings.
If your 100% benefit coverage falls short of the fee charged, the higher discrepancy does not mean the dentist is overcharging. There are no regulations on how insurance companies calculate these numbers. Wide fluctuations exist between how the insurance companies figure out these “UCR fees.”
There are also additional issues that may not be apparent when one first reads the outline coverage of what a dental insurance plan claims to cover.
Are you are considering getting dental insurance to cover dental services beyond preventative dental services?
The attached Guardian plan is for a single person, aged less than 49 years old and costs about $45 per month.
12 months of premiums will cost you $540.
Your first year of coverage will not provide you with major dental benefits. You have to pay into the plan for over a year to obtain major coverage.
In your first year, your routine preventative dental services of 2 cleanings per year, exam and x-rays at our office would cost you $330 in 2017. This insurance plan will cost you $540 in premiums. If you have good oral health and don’t need any other services, paying (without insurance) at our office would save you $210.
Waiting-Periods is when you have to pay your premium over a certain length of time before the insurance company will contribute benefits towards dental services (beyond cleanings, exam, and x-rays).
This plan states that there is a waiting period of 12 months for major services. This means that only after you have paid premiums for at least one year will your plan possibly consider paying benefits for a crown at 50% (after you pay your $50 deductible).
If the insurance company’s “negotiated fee” for a crown is around $900. After they take out the $50 deductible, their 50% coverage will pay $425 towards that $900 crown.
If you have been paying your premium into the plan for 16 months. Then you paid in $45 X 16 months = $720.
What you got in return was two cleanings, exam, and x-rays – a cost at our office of $330. Plus $425 towards your crown. You paid $720 in premiums and got $330 + $425 = $755 in return as insurance benefits.
You still need to continue to pay $45 premiums per month, ongoing to the insurance company.
Keep in mind, that the insurance company may deny that you need a crown despite your in-network dental professional diagnosing that you do.
If you need more dental treatment than one crown, your benefits have an annual limitation amount, above which the insurance company will cease to pay any benefits (for cleanings or anything else).
The language used by insurance companies to convey their plan coverage can be unclear and confusing. For explanation purposes, let’s take a close look at this plan and please bear in mind, all dental insurance companies use similar language.
One of their statements reads:
“Get most services, including oral exams, cleanings, and x-rays covered at 100%.”
A closer reading of this policy reveals that only those preventative services (exams, cleanings & x-rays) are covered at 100%. Most services are covered at 70% or less. Regardless of whether you see an in-network provider or an out-of-network, non-participating provider.
“Charges for services provided by participating dentists are based on negotiated, discounted fee schedules”.
In-Network: You might expect that if you see an “in-network” participating dentist, your out-of-pocket expenses for services will be less. However, the savings might be dependent on the details of the dental services performed.
For example, your back molar tooth needs a filling. You want your dentist to use white filling materials. The dental plan’s “Fee Schedule” says they cover fillings at 70% at the “In-Network” dental office. So you expect to pay 30%.
What if the dental insurance benefit is based on you getting a silver mercury filling?
This mercury-based product is an FDA, and ADA (American Dental Association) approved material for dental fillings. If your 70% reimbursement rate is based on the “in-network, negotiated, discounted” fee for silver mercury fillings – you may find yourself paying more than 30%. If a negotiated fee schedule for white fillings on back teeth does not exist between the insurance company and the in-network provider, then the fees you are charged for the filling, and your payment might not be too different than if you saw a non-participating dentist.
The same situation can exist with regards to crowns. Some fee schedules are based on crown materials that are made of a base metal with a layer of porcelain laminated on top. Dental insurance companies allow for these materials to wear out and be replaced every five years. Negotiated fee schedules are typically based on these crown codes. If you’d rather different dental materials be used for your crown (such as gold or all-porcelain) – then you may well find yourself paying extra. These crown materials (gold or all-porcelain) would be outside of the negotiated fee codes at the in-network office for metal crowns fused with porcelain.
The alternative all-porcelain crown is more Biocompatible for you and can be made in the dental office, while you wait. That’s right – no temporaries and in one appointment. Check out our website page on CAD-CAM Dentistry.
Another statement on this insurance policy reads:
“If you choose to see a dentist outside of the network, you’ll be reimbursed on Usual and Customary (UCR) charges. You would be responsible for the deductible and any amounts over the UCR as well as any co-insurance”.
Deductibles are what you pay first before the plan pays benefits. The second sentence in the insurance statement above would give the impression that you could avoid paying any deductible if you go to an in-network dentist.
The reality is that you will have to pay $50 deductible to any dentist (in-network or out-of-network) on all basic and/or major services.
Co-Insurance is what you have to pay after the deductible has been paid by you. For example, if the insurance says it will pay 70% of a basic service then your co-insurance amount would be 30%. Again, for all services outside of preventative (Exams, Cleanings & Xrays) you still have to pay the co-insurance amount as well as the deductible. And it doesn’t matter whether you see an in-network or a non-participating dentist.
Another way to say that last sentence, in the insurance statement, would be:
You would be responsible for the deductible as well as any co-insurance for basic & major services, regardless of whether you see an in-network or an out-of-network dentist.
Another statement on this insurance policy reads:
“You can see any dentist you want but save up to 35% when you visit a dentist that participates in the network”.
UCR: Not every procedure at a non-participating dentist’s office is necessarily at a higher fee, despite what the insurance company would like you to think. It might be almost the same fee, or it could be lower. If there is a higher discrepancy, it doesn’t mean that the dentist is charging too much. Insurance companies don’t reveal what methodology they use to calculate UCR (Usual, Customary and Reasonable). It is impossible to know if this “reasonable” fee stated by the insurance company does adequately reflect the fees of the dentists in that area. Did the insurance company use a “cut-off” level of 80%, 70% or lower percentile in making their determinations?
How up-to-date are the insurance companies’ calculations?
There are no regulations on how insurance companies calculate these numbers. Wide fluctuations exist between the insurance companies regarding these “UCR fees.” It is important to read the details of these plans very carefully.
Questions to consider include
Just how much will I be paying into the plan compared to $$ I expect to get back in benefits?
You should be getting a lot more back in benefits that you are paying into the plan.
Do I have a choice in requesting dental materials that will be used in my care?
If I choose materials that are not on the “negotiated fee schedule” – how much extra expense am I paying out of pocket, regardless of whether the dentist is in-network or a non-participating provider?
How long is the waiting period?
Policies with a low monthly premium can have lower benefits.
If my dentist is not involved in a negotiated, discounted fee schedule – is there something about their office (training, experience, availability of appointments, technology, materials, etc.) that is different. If you can’t think of any, then ask your dentist.
We can help
With over 30 years’ experience in processing dental insurance – at Asheville Holistic Dentist, we know what it takes to get your claim processed. Our expert team is highly efficient and patient-focused when it comes to processing dental insurance claims. If you find your existing dental benefits coverage needs additional financial assistance, we do offer payment options, including long-term, competitive financing plans (often at 0% interest rate) and prepayment courtesy savings.