Dental Insurance 101 —
Ok, so we all know that sometimes insurance can be
complicated to understand. It doesn’t
have to be that way once you know what you are looking at. Let’s go over the basics of dental insurance
to help you get a better grasp of it.
There are a bazillion ways that dental plans are written up,
so we are just going to look at a typical generic plan and focus on that
(please read your plan carefully to check on all the specifics).
First off, you have a dental maximum amount of dollars to
use per your dental year. This year
typically runs from January 1 to December 31.
Some plans run on a different schedule due to hire dates and things like
that, so you may have one that runs July 1 through June 30. Knowing these dates will allow you to better
prepare yourself to figure out how much time you have left to use up your
remaining amount of benefit dollars and when your new year starts over with a
new maximum to use. Once you hit this
maximum amount of dollars, that’s it until a new year starts! Each member of the family on the dental plan
has a maximum amount to use. So, if the
plan has a $1,000 maximum, it means that you, your spouse and child each
individually have $1,000 of dental benefits. The maximum generally includes all
of your services including exams, cleanings and x-rays, along with other things
like fillings, crowns, dentures and so forth.
We’ve heard some patients say that they thought cleanings and exams are
separate from the maximum, but that would be unusual.
Next: Deductibles.
Just like your car insurance or health insurance, dental insurance
generally has a deductible that you need to meet. This deductible (we see them a lot as $25 or
$50 amounts) has to be paid by you prior to your insurance paying for dental
treatment. Most likely, the deductible
is waived for things like regular cleanings, x-rays and exams, which are
considered preventive care. It does,
however, apply to what is considered basic and major services. Basic services generally include fillings,
root canals, and extractions and some extensive cleanings. Major services are usually things like
crowns, bridges, partials and dentures.
Let’s look at a break down to show you how the deductible works.
Let’s say you have a $50
deductible and you need to have a filling done, which costs $150 (let’s sneak a
maximum in here also).
Dental Maximum: $1,000 Deductible: $50 (applies to basic and major)
Coverage:
Preventive: 100%
Basic: 80%
Major: 50%
Ok, your insurance plan covers 80% of fillings after your $50 deductible is met. Take that deductible off the top to start with and set it aside.
$150 (cost of filling)
-$50 (deductible)
_________________
$100 that your insurance will now pay 80% after deductible
80% of $100 is $80, which leaves you a 20% co-payment
of $20
Add that $20 co-payment to the deductible that you owe:
$50 deductible + $20 co-payment= $70 out-of-pocket cost to
you
Now that your deductible is met, you should not have to meet
it again until your new year of benefits starts over.
And, since your insurance will be paying $80, that will be
$80 subtracted from the $1,000 maximum leaving $920 to use for the year.
There can be some tricky situations, as we all know happen
when dealing with dental insurance.
Sometimes your insurance has something called a pre-existing condition,
just like most health insurances. This
will prevent them from paying for certain things due to the initial occurrence
happening prior to your coverage starting with that particular plan (confused
yet?). Maybe at one point in your life
you had to have a tooth removed; let’s pretend when you were 31 years old. Now, at 37 years old, you want something to
replace that tooth, however you started a new job with different dental
insurance and it has a pre-existing condition clause or what may be called a
missing tooth clause. The insurance will
not pay for a bridge to replace that tooth because you had it removed prior to
starting with this insurance plan.
Another issue might arise where you have a waiting period
that needs to be met on a new insurance plan before you have any coverage at
all. Sometimes it will be a 3-month wait
but there are times that you have to be covered under that dental plan for a
year before they will cover anything major like a crown or partial
denture. Be aware of these things before
you jump the gun. It’s exciting to have
dental insurance when you haven’t had it for a while, so although you may be
raring to go to get dental treatment done, just make sure that a waiting period
doesn’t prohibit you from moving ahead.
Szmanda Dental Center can find out from your insurance plan
what your coverage is and any stipulations it might have. We can also preauthorize proposed treatment
prior to you having it completed so you can be aware of exactly what you will
have to pay out-of-pocket. Please talk
with our fantastic front desk team for further information on your dental plan
and to schedule an appointment. We are
here to help! To see a list of our current insurance providers click the following link: www.szmandadental.com/financial.html
