We have a lot of patients who aren’t sure how their insurance works and what they should expect in covered services. We hope that this blog gives you a better understanding about your dental insurance.
When a patient selects a Dental Insurance the patient receives a booklet with information pertaining to the Insurance that has been selected.
- Frequencies on exams, images and cleanings
- Yearly Deductibles for In/Out network plans
- Yearly maximum for In/Out network plans
- Limitations on certain procedures
- Age Limitations
- Information on percentage covered for diagnostic/preventative procedures such as cleaning and x-ray
- Information on percentage covered for basic/major percentage
Patient is also able to Register online to view their Insurance plan. Patients are able to search for a Provider who is In Network for the selected Insurance.
In Network Vs Out of Network :
- In Network Provider/Dentist is the one who takes the specific dental plan that has been chosen by the patient for example if a patient has a PPO plan with Blue Cross Blue Shield Insurance, the “In Network provider” would be the one who is contracted with Blue Cross Blue Shield PPO plan.
If a patient goes to a provider that is considered an “Out of Network Provider” means that the provider is not contracted with the specific plan that the patient has chosen but that does not mean that the provider cannot accept the insurance. what that means is that your insurance company has not negotiated their fees with that provider/dentist and the fees may be higher than the insurance fees. The dentist still has the authority to offer insurance fees to you without being in network with the insurance.
- Out of Network Provider-Dentist is the one who is not contracted with that specific plan, for example, if a patient has a DMO dental plan and the provider is only contracted with a PPO dental plan. This means that the patient could potentially pay more out of pocket or pay the whole visit due to the Insurance refusing to pay for the visit. In this case the patient is responsible to pay in full. Again, the dentist might be able to lower your fees or offer special arrangement for you.
In network plans normally pay by percentage:
- Diagnostic/preventative procedures such as exam, x-ray, cleaning: The Insurance normally pays 100% Patient pays $0.
- Basic procedures such as restorative, root canals: The Insurance will normally pay 80% and patient will pay 20% of the procedure.
- Major procedures such as crowns, inlays, post & core build up: A lot of insurance plans pay 50-80% and patient pays 20-50%.
Out of network plans are different and usually have a higher deductible:
- Diagnostic/preventative procedures such as exam, x-ray, cleaning: Insurance pays 90 to 100% and patient pays 0 to 10% and patient is required to pay the deductible.
- Basic procedures such as restorative, root canals:: Insurance pays 50-70% and patient pays 50-30%.
- Major procedures such as crowns, inlays, post & core build up: Most insurance plans pays 50% and patient pays 50% and in some cases the insurance plans might not cover for Major procedures.
Some Dental plans have a Deductible Between $50-$100 depending if the plan is In/Out of Network with the provider. Deductibles are paid 1 time per each year by the patient and it is usually due when a basic or major procedure is done.
Maximum Allowable Amount:
Insurance Plans can also offer a maximum, for example $1500.00 per year. This maximum is used for all Diagnostic/Preventive, Basic, and Major procedures. The Insurance will subtract every procedure from the Maximum Allowable Amount. If the patient is maxed out, then the patient will pay the office fees until the following enrollment year.
Always call every Insurance company you are registered with and ask questions. When verifying insurance online it might not provide enough information.
Possible limitations of your insurance plans:
- Restorative Limitations: Insurance covers for amalgam restoration on molars and does not cover composite fillings (tooth color fillings). This is called a down grade and the patient has to pay the difference in order to get composite fillings.
- Waiting Period: Insurances can have a waiting period during which a patient may not be covered for some procedures such as crowns. This period may be up to 12 months.
- Full mouth x-ray (FMX) and panoramic x-ray (Pano): You can only get either the FMX or a Pano. The insurance will not pay for both. Those maybe covered only once every 3 years.
- Full mouth debridement (FMD) and complete exam: The insurance will pay for either a FMD or a complete exam and not both.