What You Should Know About Dental Insurance

Dental insurance can be a nice benefit to have.  Many of my patients have it in some form. It is designed to defray a portion of the cost of necessary dental treatment. In reality, it is more like a benefit plan (actually, it’s more like a coupon) than true insurance.  Your benefit plan will have a yearly deductible, a breakdown of coverage limitations and exclusions, a yearly reimbursement maximum, exclusions, restrictions, etc.

Dental benefit plans were first constructed mostly in the 1970’s and have changed very little since then.  The typical maximum annual benefit available over fifty years ago was $1,000.  All these years later, even with increased insurance premiums, coverage amounts have remained basically the same.  Based on inflation, dental plans today should be allowing around $8,600 in benefits!  So, why don’t they?

At Miller Dentistry, we encourage our patients to become familiar with their own dental benefit plan.  This is what you need to know:

• You don’t necessarily have to choose a dentist that is on the network provider list they give you.  Most plans allow you to choose your own dentist.  Make sure yours is one of those.
• Your dental plan has benefits negotiated in a contract between you/your employer and the insurance company.  It can be difficult to obtain all the confidential information pertaining to your particular plan.
• Your plan has a limited reimbursement amount (annual maximum) for services.
• Your plan has a deductible, or an amount you are required to pay before benefits are available.
• Your plan will likely have restricted fee allowances for each service based on the way the plan was constructed.  This information is not always public knowledge and is different with each plan, even within the same company, and will affect your reimbursement.
• Your plan will likely have exclusions (such as a Missing Tooth Clause or Implants or Adult Orthodontics, etc.).
• Your plan will pay a percentage of your services based on fee allowances set forth in the contract arranged between you/your employer and the policy administrator.
• There are basically four categories affecting coverage for dental services:

• 1. Category I – Preventive – Generally includes basic cleanings, most x-rays, routine examinations, and possibly dental sealants.
  2. Category II – Basic – Usually allows some benefit for fillings, root canals, gum disease therapy, and extractions.  However, some plans may classify any of these services as major.
  3. Category III – Major – Typically provides only limited benefits for crowns, bridges, and dentures.
  4. Category IV – Other – May cover some costs for Invisalign, braces, and appliances along with other miscellaneous services.

• Your plan may require that some services be “pre-authorized” which does not mean guaranteed coverage.  It is your responsibility to request a pre-authorization of services if it is required or desired.
• Your plan will probably have a waiting period of up to one year or longer for some procedures.
• Your plan may have a restricted provider list and will dictate who you can use as your dentist.  This could be someone you do not trust or like.
• Your dental insurance company may deny your benefits for any reason.
• Your plan will have limits and exclusions that are unique to your contract.  Please read the fine print.

Ultimately, it is your responsibility to know your dental insurance contract agreement.  My office files your claim and handles basic disputes through appeals. Keep in mind, dentists do not work for, nor are they representatives or employees of any insurance company.  Estimation of benefits is based on information provided by your insurance policy carrier and cannot be guaranteed by any dentist.

For those who don’t have dental insurance, Miller Dentistry offers our Dental Membership Plan that covers routine cleanings, checkups and x-rays and gives a 20% discount off most dental services for a low monthly fee.  You can find out more by visiting MillerDentistry.com or calling (832) 905-0900. It’s a very popular option with my patients.

My best advice is to find an honest dentist that listens to you, treats you with respect.  Like anything else, you get what you pay for.  The value of a trustworthy, friendly, skilled dentist may go beyond your insurance coverage, but you will definitely be better off in the long run.