Ohio Cosmetic Dentistry

Monday, August 13, 2007

Dental Insurance Facts

46% of the population has no dental insurance. Individual coverage is available, but finding the right policy can take a little digging. And, like the group coverage offered through employers, is doesn’t always pay for everything.

Some individual policies are more expensive and in some cases less comprehensive than what you might get out of a group plan.

Monthly premiums average anywhere from $12.00 to $50.00 per person.

Consumers buying there own coverage have to look beyond first-year premium quotes. Some companies offer a great rate for the first year, during which there is a waiting period on any type of dental work, then the company raises the rates after the first year.

To find Insurance coverage:
· You may contact an insurance broker or your current insurance carrier.
· You may contact the Ohio Dental Association, and they will let you know what plans are offered in your area.
· You may also contact the National Association of Dental Plans or Delta Dental, which lists plans by state.

Some Questions Regarding Your Dental Benefits:

Your plan sponsor should be able to explain the individual design features of your plan. Features to understand include: exclusions, limitations, patient copayments, and annual or lifetime benefit maximums. If you have additional questions regarding your treatment or dental insurance, your dentist’s office should be able to answer additional questions for you.

If your dentist recommends a treatment that your plan does not pay for, it does not mean, the treatment is unnecessary, it simply means that according to your dental plan the treatment is not a covered benefit, which means they are not liable to pay for that specific procedure.

If your dentist recommends a crown as opposed to a filling, because of the size of the restoration, and your insurance will only pay for the level of benefit for the least expensive ways to repair the tooth, regardless of the decision made by you and your dentist as to the best treatment. Sometimes special circumstances may be explained to the third party by a narrative done by your dentist office, but there is no guarantee the insurance will pay, even after receiving the explanation.

In the case of exclusions, you should base your treatment on your specific dental needs, not on what your insurance benefit level will pay.

If your dental plan says that it will pay 100% for 2 dental checkups per year, and you receive an explanation of benefits from the insurance, stating that you owe the provider, it means your insurance has paid 100% of the Usual, Customary and Reasonable fee. This means the insurance has set what the plan considers to be a “customary fee” for each dental procedure. If your dentist’s fee exceeds the customary fee, your benefit will be based on a percentage of the customary fee instead of your dentist’s fee.

However, if the dentist’s charges exceed the customary fee, this does not mean your dentist has overcharged for the procedure. These plans pay a set percentage of the dentist’s fee or the plan administrator’s “reasonable” or “customary” fee limit, whichever is less. Although these limits are called “customary”, they may or may not accurately reflect the fees the area’s dentist charges. There is a wide fluctuation and lack of government regulation on how a plan determines the “customary” fee level.

A prime consideration and a major motivation in choosing one plan over another is exactly what type of coverage your entire family will need. If your employer offers more than 1 plan, be sure to look at the exclusions and limitations of the coverage as well as the general categories of benefits.

Your dental insurance plan should describe the benefit levels and list any exclusions or limitations to that coverage. They should also identify who is eligible for coverage under the plan and when the coverage goes into effect.

Your dentist cannot answer specific questions about your dental benefit or predict what your level of coverage for a particular procedure will be. This is because plans written by the same third-party payer or offered by the same employer may vary according to the contracts involved. Therefore, you should ask the plan purchaser or the third-party payer to answer your specific questions about coverage.

If your dentist is not on the list of dentists provided by your employer, you can always still go the dentist of your choice. The question is whether you will have benefit coverage for the treatment you receive if it is provided by a dentist who is not on the plan’s list. This depends on the contract between the employer, the listed dentists and the plan administrator. Under certain contracts (PPO), patients are given a financial incentive to go to certain dentists but do receive some level of dental benefit, regardless of the treating dentist. Other plans do not provide any benefit coverage for treatment given by non-participating providers. Patients should check their dental benefits, before switching dentists or starting somewhere new, to determine what the benefit levels are of that particular dentist or dentists not a specific list.

Your dentist should submit a treatment plan to your insurance before any major work is completed to be sure of what benefit level your insurance will pay and what you will be responsible for in the end. This “predetermination of benefits” however, is just an estimate, not a guarantee. A “predetermination” means when the dentist submits your treatment plan to the insurance, a dental consultant will review the treatment plan and determine what benefits your plan will provide. You may want to review your benefit prior to receiving treatment, but the final treatment decision would be a matter between you and your dentist, regardless of your benefit.

Direct Reimbursement programs-reimburse patients a percentage of the dollar amount spent on dental care, regardless of what the treatment category is. This method does not exclude coverage based on the type of treatment needed and allows the patients to go to the dentist of their choice.

“Usual, Customary and Reasonable” (UCR) programs-allow patients to go to the dentist of their choice. These plans pay a set percentage of the dentist’s fee or the plan administrator’s reasonable or customary” fee limit, whichever is less. Although, these limits are called “customary”, they may or may not accurately reflect the fees that area dentists charge. There is a wide fluctuation and lack of government regulation on how a plan determines the “customary fee schedule.

Table or Schedule of Allowance Programs-determine a list of covered services with an assigned dollar amount. That dollar amount represents just how much the plan will pay for those services that are covered. Most often, it does not represent the dentist’s full charge for those services. The patient pays the difference.

Preferred Provider Organization (PPO)-plans under which contracting dentists agree to discount their fees as a financial incentive for patients to select their practices. If your dentist is not a participating provider, the patient will have a reduction or complete loss of benefits.

Should You Purchase Dental Insurance?

Many people are struggling with the decision of whether or not to purchase dental insurance. Whether you are purchasing insurance through your employer or independently, be sure to investigate several different plans and ask questions about the following factors:

Affordability and Yearly Maximum
The yearly maximum is the most money that the dental insurance plan will pay within 1 full year.
In/Out of Network Dentists
Most independent dental insurance plans will only pay for your dental services if you go to a contracted and participating “in-Network Dentist”
Find out if you are required to go to a participating dentist or if you can choose your own.
If the plan requires you to go to a participating dentist, be sure to ask for a list of the dentists in your area with whom they are contracted, so that you may go there.
UCR (Usual, Customary, and Reasonable)
This means that insurance companies set their own price that they will allow for every dental procedure that they cover.
This is not based on what the dentist actually charges, but what the insurance company wishes to cover.
If you are on a policy that requires you to go to a participating provider, you should not be charged the difference between the two prices.
A contracted dentist has an agreement to write off the difference in charges.
If you go to an “out of Network” provider, you may be required to pay the difference out of your pocket, however, you can not put a price tag on quality dental care.
Major Coverage
Dental procedures are broken down into three categories:
Preventative
Basic or Restorative
Major
o When comparing dental plans, make sure that all three of the above categories are covered in the policy that you choose. There are many companies that do not cover major charges.
o Insurance companies may consider crowns, bridges, root canals, dentures, and partials to be “major” dental procedures.
Waiting Periods
A waiting period is the length of time an insurance company will make you wait after you are covered before they will pay for certain procedures.
It is important to know what the waiting periods are, because you could have dental work completed, and if there is a waiting period, you were not aware of, they could come back and not pay anything towards the dental treatment.
Missing Tooth Clause and Replacement Period
90% of dental insurance policies carry a “Missing Tooth Clause” or a “Replacement Clause”. Many carry at least 1 clause but some insurance companies have both.
A missing tooth clause protects the insurance company from paying for the replacement of a tooth that was missing before the policy was in effect.
A replacement clause is similar except that the insurance company won’t pay to replace dentures, partials, bridges, etc.. until the specified time limit has passed.

5 Reasons to use your Dental Insurance Before the End of the Year:

1. Yearly Maximum
a. The amount averages between $1000-$1500 per person, per year.
b. The Yearly maximum renews every year (on January 1st if your plan is on a calendar year).
c. Unused benefits will not roll over.
2. Deductible
a. The deductible is the amount of money that you must pay to your dentist out-of-pocket before your insurance company will pay for any services.
b. The average deductible varies from one plan to another, but is usually around $50.00 per person, per year.
c. Your deductible also starts over when your plan rolls over every January.
3. Premiums
a. If you pay your premiums every month, you should be taking advantage of your benefits.
b. Even if you don’t need treatment, you should always have regular dental check-ups to prevent cavities, gum disease, oral cancer, and other problems.
4. Fee Increases
a. Some dentists raise their fees at the beginning of the year due to cost of living, materials and equipment.
b. A fee increase can also make your copayment higher.
5. Dental Problems can get Worse
a. By delaying dental treatment you are risking more extensive and expensive treatment.
b. What may have started out a small cavity could turn into a root canal later, if left untreated.

Call your dentist and schedule an appointment to use those benefits.

Regardless of why an insurance plan is offered, its intent is the same: to help individuals by paying for a portion of the cost of their dental care.

Treatment decisions must be made by you and your dentist. While dental benefit coverage should be taken into account, it should not be the deciding factor in your choice of treatment.

posted by Dr. Barkett at 12:20 PM