You have dental insurance, and it should cover your dental procedures, right? Think again. It’s a misconception people, in general, have of dental insurance. Dental insurance benefits, a frequent misunderstanding that can be frustrating for both a dental office and those insured.
So why isn’t it covering your all of the dental procedures you need?
Before we can answer that we need to clarify that medical insurance is very different from dental insurance. Most insurances often referred to it as “dental benefits” than coverage. Typically, included in your dental benefits often depends on the plan you’re in, and usually, it’s only meant to cover part of your expenses.
So when you receive a bill for denied services, or a treatment plan with procedures not covered, here is some information as to why.
Dental insurances are typically described as a “100-80-50” coverage. What does that mean? It means 100% coverage is towards preventive and diagnostic care such as check-ups and cleanings. 80%, although sometimes 70% to 80%, coverage is towards basic procedures such as fillings and 50%, or less, coverage is towards major procedures like crowns, root canals, and bridges.
Dental insurance only covers up to a specific annual limit typically between $1000 – $1500 annually. Every year you are given a yearly limit by your insurance company of what the insurance will cover up to for your dental needs. As you can see, it’s an insufficient number for the year, and you can quickly exceed it if you have extensive treatment to be done. In addition to the percentages of what is covered by your dental insurance, this limited annual coverage is quickly used, leaving you responsible for 100% of the remaining treatment.
There are three variations of dental insurance that have limitations on coverage and where you can go. The HMO, health maintenance organization, which restricts coverage to dental professionals within their limited network. PPO, preferred provider organization, policies charges reduced rates within their network of dentists, which provides you with contracted fees from your dentist. Some PPO’s allow you to see a Dentist outside your network and pay less towards those services. Indemnity plan, the last of the three, will enable patients to look at any dentists and typically picks up a percentage of the costs.
Dental insurances typically do not cover pre-existing conditions. If you already had an existing dental problem and are hoping your insurance will cover it, think again. Pre-existing conditions are not covered by insurance which means you’ll have to pay for the treatment you need out-of-pocket. An example is a missing tooth that you had before your current dental coverage, most likely, having it replaced with an Implant would not be covered, it would fall under pre-existing.
They have limitations and exclusions to their plans. Some insurances will place restrictions on what they will cover. Not ideal, I know, but they do anyway. These limitations can include how many times you come in for particular procedures. Then there are the exclusions which refer to the dental procedures not covered by dental insurances.
When you take into consideration the annual limit you have, along with restrictions that apply, chances are your dental insurance isn’t going to be paying for all your dental needs. You will. But that doesn’t mean you should avoid getting the dental treatment you need. Besides having your insurance cover a percentage of your dental procedures, you could look into getting a dental discount plan. A dental discount plan can help reduce the cost of procedures and enable you to maintain a healthy smile.
If you have any questions regarding your insurance benefits, please feel free to call us today at 801-747-8018.