Understanding Your Dental Insurance

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A report stating that the dental insurance industry generated $82+ billion dollars in the U.S. in 2020 is a pretty clear indication that dental insurance is here to stay. About 90 percent of employers with 500 or more employees offer dental benefits and about 50 percent of all companies offer dental coverage. Dental insurance is becoming a common health benefit. Self-employed are the most likely to not be covered. This being said, there are other options available for people who want to maintain a healthy mouth.

The purpose of this blog is to educate you in understanding what your insurance can do for you, what it can’t and other options that are available through our office that may save you time, money and the headache of dealing with insurance companies.

What Insurance Covers And What It Doesn’t

Insurance often covers cleanings and exams, but insurance does limit how many per year. There are limited or problem-focused exams dealing with acute issues that have coverage limits as well, primarily in the frequency areas. In the more extensive treatment plans, there is a range in coverage anywhere from 50% to 100% for service meaning that the patient can be responsible to cover the cost of treatment whatever the difference. In addition, it depends if a dentist is in-network with the insurance company or not. If a provider is in-network and is contracted with the company for that particular plan the insurance will pay their fee schedule assuming they cover that particular procedure. There are those insurance plans where the provider is out of network where the patient is responsible for the disparity between the insurance converge and the office fees.

How Much Of A Procedure Is Covered?

Very routine procedures including fillings, cleanings and extractions are rarely scrutinized by the insurance company. A dentist’s diagnosis is generally acceptable to reimburse for the service. On the other hand, crowns, bridges, wisdom teeth removal and implants are scrutinized more and can be denied for coverage by insurance companies or can be covered at a percentage of the cost of the procedure. If the insurance only covers a portion it means that the patient is responsible for the remainder of the fee. Sometimes we don’t know what the insurance company will cover until the Explanation Of Benefits (EOB) is sent to the office, making it difficult to accurately quote the patient.

Treatment Options, Restrictions And Downgrades

Treatment options continue to revolutionize. Unfortunately, insurance companies have not recognized some of the current treatments as being the best for patients. This can sometimes mean that treatments are downgraded if any coverage will be allowed. For instance, instead of an implant that functions as close to a natural tooth as possible, the insurance company might offer coverage for a removable prosthetic. This is what Dr. Spear often calls grandma and grandpa teeth because they are outdated. We always do our best to have as much of the procedure covered by insurance and give as much narrative as necessary to make that possible.

Understanding Dental Insurance Deductibles

There is something else that can be confusing when dealing with dental insurance because it is different than the medical and even auto insurance standards. With dental insurance your deductible is not like your medical deductible where you use it up then the fees are decreased by a percentage or coverage is increased a percentage, dental insurance is the opposite where insurance pays until a certain price then stops paying and the patient is left paying the remainder. For example, I have known people who wait for certain procedures until their medical deductible has been met so they can get more coverage. With dental, if you want and use more of your allowable coverage you will only end up paying more.

Other Payment Options:

The Spear Loyalty Program For Those Who Don’t Want Dental Insurance

Where insurance can be beneficial it can also leave the patient and dentist with limited options for what is covered and what is actually best. Meaning that the patient may be left paying out of pocket for the best possible option. Understanding that this has been and will continue to be an issue we’ve created a plan that removes the insurance company. It still offers an annual premium like you may pay with an insurance policy AND preventative care is provided under that premium. Other treatment that is needed is then discounted 20% off of our fee schedule. And, where insurance companies often dictate 100% what the dental practitioner must do and charge for services, we as the plan administrators can work with the patient more and offer far more flexibility than an insurance company.

We Are Here To Help

Our team is here to help you understand your options for treatment. If you have any questions about your plan, your treatment or the options we offer please don’t hesitate to contact us at 817-920-1488.