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Top Dental Insurance FAQ Answered – Part 1

Top Dental Insurance FAQ Answered – Part 1

Are You Confused By Your Dental Insurance?

Part I

If you’re like the majority of people we talk to on the phone and see in our office the answer is a resounding YES! Well, we’d like to give you the answers to some insurance questions we hear most frequently in a simple and straight forward way that you can understand. So let’s jump right in!

1. Do you take my dental insurance? or Are a preferred provider of my dental insurance?

Hands down these are the top questions we hear, but although they may seem like the same question phrased differently there are some important distinctions to be made. Ninety-nine percent of the time if you ask a dental office, “Do you take my dental insurance?” they will tell you yes. That yes is because most offices are happy to take a check from any insurance company no matter who it is. The true heart of the matter lies in the second question, “Are you a preferred provider of my dental insurance.” The first place to begin answering this question is to be sure you understand what a preferred provider is.

A dentist becomes a preferred provider by entering a contract with the dental insurance company. In a nutshell, these contracts create an agreement between the doctor and insurance company stating that the doctor agrees to provide dental services at a discounted rate in exchange for having patients directed to his office by the insurance company.

Here’s a typical senario:

– Dr. Molar’s fillings are $200 (full fee price)

– Dr. Molar’s contracted reimbursement rate for XYZ insurance is $150. The $50 difference is written off by the doctor and is the price he pays (or agrees not to be compensated) for being a contracted dental provider.

So why does it matter if the dentist is a preferred provider?

One of the ways your dental insurance company may encourage you to use dentists they have a contract with is that they will reimburse at a higher rate for doctors they have contracted with. It will save you some (not all) out of pocket costs if you choose a doctor who is contracted with your insurance company.


2. How does my deductible work in dental insurance?

First it’s helpful to know when your deductible will and won’t kick in. With most dental insurances your deductible is paid at the first restorative service. A restorative service means that the dentist is doing something that fixes, a.k.a restores, your tooth. Is a cleaning a restorative service? Nope, a cleaning doesn’t do anything to change or fix your teeth. Is a filling a restorative service? Yes, filling is a procedure that fixes your tooth.

Some examples of things that are NOT considered restorative are: cleanings, x-rays, exams, fluoride treatments, etc. These types of services are considered preventative and are covered 100% by most dental insurances.

Some examples of things that ARE considered restorative are: fillings, root canals, extractions, crowns, bridges, etc.

Here are some key features about dental insurance deductibles to note:

-The deductible is usually a very low amount; $25-$50 is common. In contrast to medical insurance deductibles which are usually $1,000 or more.

-It is only paid once a year. So if you got a filling in February you would pay your deductible at that time. But if you broke your tooth in November (didn’t the dentist tell you not to crunch on ice), you wouldn’t need to pay your deductible again because you’d already paid it for that year.

-It will only need to be paid if you need restorative care. If you go all year without needing any restorative treatment then you won’t end up paying a deductible that year. Yay!

-Each person on the plan has his/her own deductible. Mom may have paid her deductible when she got a crown in June, but if Dad needs a filling at his check-up in August he’ll need to pay his own deductible.

-After you’ve paid your deductible the insurance company will begin to pay their percentage towards you treatment. The percentage your insurance will pay depends on your policy and the type of treatment you’re receiving. For basic dental services it is common to have 80/20 coverage (they pay 80% you pay 20%). For major dental services it is common to have 60/20 coverage (they pay 60% you pay 20%).

That triggers our third question.

3. Which types of services are considered basic and which are considered major by dental insurance and why it matters?

The coverage of most dental insurance is actually tiered. The type of dental work you need done will determine how much your insurance will pay. Most insurance companies classify procedures as either basic or major.

Basic Services are typically covered at 80-90%. Examples of basic procedures are: fillings, extractions, root canals, scaling and root planing, and periodontal maintenance.

Major Services are typically covered at 50-60%. Examples of major services are: crowns, bridges, implants, partial dentures, bone grafts, inlays, and onlays.

In conclusion, let’s pull all the information we’ve covered today together into an example patient.

John Doe needs a filling and he has XYZ insurance. Dr Molar is a preferred provider for XYZ insurance so the cost for the filling is $150 (a $50 reduction from the full price of $200 due to the contract Dr. Molar has with XYZ insurance). John Doe has a $25.00 deductible on his policy, which he must pay because this is the first restorative service he’s gotten this year. Once he’s paid his deductible the balance is $125.00. The insurance company will pay 80% of the $125.00 (or $100), and John must pay the remaining 20% ($25.00).

John Doe’s Out of Pocket Cost- $25.00 deductible + $25.00 (20% of balance after the deductible)= $50.00

XYZ Insurance Payment – $100.00 (80% of balance after deductible)

This example and the percentages of coverage mentioned above are pure fiction created to simplify the math. Your dentist’s fillings may cost more or less than the ones in our example and your insurance company may pay more or less based on your individual coverage. But hopefully now you understand the concepts well enough to be able to look at your policy and have an idea of how it works.

In part II of this series we will explain annual maximums, what it means when your insurance policy renews or starts a new year, and what a composite downgrade is.

Until then, keep brushing, flossing…and don’t skip your dental cleanings!