The consumer’s guide to dental insurance

In this article, we present dental insurance in greater depth so that the average American consumer will have a better grasp of this type of insurance.

Advantages and disadvantages of dental insurance plans

Advantages

  • May cover more than just teeth protection.
  • Dental expenses may be lessened significantly.
  • The chance to make regular visits to the dentist, thus helping in the prevention of dental problems.
  • In times of emergency, the insured individual can to his dentist right away, not having to think about expensive charges.
  • Provides peace of mind for.

Disadvantages

  • Monthly premiums are not cheap.
  • Some services may not be covered, for instance, braces which may be needed by some people.
  • There may be limits with regard to dental charges that can be made in a year. This could be a problem especially if a consumer requires regular check-ups.
  • Policies may be complicated too understand.
  • Some policies offer a limited set of dentists - if a consumer has a dentist whom he prefers but is not in that list, this could be a disadvantage.

What is covered and not covered in a dental insurance policy?

Dental insurance coverage may vary from one policy to another. There are different co-pay levels as well as certain procedures may get full coverage by the insurance company while other procedures may require co-payment on the part of the policyholder.

Usually, the following are covered:

  • Preventive and diagnostic care - many plans cover both preventive and diagnostic procedures, they either provide full coverage of costs or require co-payments from the insured individual. These procedures include X-rays, fluoride treatment, check ups, routine cleaning, and similar procedures that prevent or detect gum and tooth disease.
  • Basic procedures - this covers gum care, tooth removal, chipped or cracked tooth repair, cavity fillings, and may even cover root canal surgery. In certain plans a small co-payment amount may be required.
  • Major dental procedures - may include surgery, implants, dentures and braces.

The following are usually not covered:

  • Procedures that are considered cosmetic like tooth bleaching or whitening, tooth veneers, and bonding.
  • Orthodontic procedures are not covered by many plans but finding an insurance company that will provide this coverage is possible.

Types of dental plans

The common types of dental plans can be categorized as follows:

  • Direct Reimbursement plans - these types of plans reimburse consumers with a percentage of the costs of dental care. That percentage is predetermined in the plan. The benefit of this type of plans is that it allows the consumer to be under the care of the dentist of his choice. This plan, therefore, makes it possible for the consumer to work with his dentist in determining solutions that will be beneficial to him health-wise and budget-wise.

  • Usual, Customary & Reasonable - these plans typically allow consumers to get the services of their dentist of choice. Payments are a percentage of the fees charged by the dentist or the fees set by plan's administrator, whichever amount is the lesser one. The limits followed by these plans are a result of the agreement between the buyer of the plan and the plan's third-party payer.

  • Table or Allowance plans - these plans follow a list, which dictate what services are covered and what the corresponding dollar amount is for each service. The amount set is the limit as to how much the insurance company will shoulder for a particular covered service. The difference in the amount allowed and the actual charge is shouldered by the consumer.

  • Capitation plans - these dental plans have a working arrangement with contracted dentists to whom they pay a fixed amount, typically on a per month basis, for each individual or family enrolled in the plan. These dentists provide a pre-determined set of services to the covered individuals at no charge with a few services requiring co-payments from the covered consumer.

How costs are pre-determined

In some plans the consumer or his dentist prepares a treatment proposal for consideration of the dental plan's administrator prior to receiving treatment.

The dental insurance company reviews the plan and determines the following: the individual's eligibility, the services that will be covered, the eligibility period, the co-payment requirements as well as the maximum amount limits.

In certain cases, predetermination may be a requirement for procedures that go over the dollar amount limits. The process for predetermination is also referred to as pre-authorization.

Limitations of dental insurance plans

The insurance provider may also set yearly limits on benefits. In many cases, the yearly limits are adequate to cover regular preventive dental care. Given the information on what the limits are for a certain plan, the consumer can better plan out with his dentist on how to maximize coverage.

Limits are implemented by putting a cap on the dollar amount that a consumer can receive and also by putting restrictions on the number and the type of services and procedures that can be covered. Some dental plans lower their costs by excluding certain treatment or services.

Ways to save when purchasing a dental plan

  • Do not pay for a plan that is more than what you need. It is therefore important to sit down with your dentist and review your dental care needs first before you go around shopping for coverage.
  • Read thoroughly the details of the plans available or offered to you. Start with visiting trusted websites for reviews and feedback. Items to look into are coverage, exclusions, limits, payments and how benefits are calculated.
  • Opt to bundle your dental plan with your health insurance coverage. Many insurance companies offer the choice of bundling dental coverage with health insurance. A consumer may get discounts with this choice.
  • Opt for a plan that has a network. Consider this if you are not picky with dentists you go to. By staying within a network you are likely to get discounted rates than opting for independent dentists.

How to get the most out of a dental plan you already have

  • If you already have a plan, get the most out of it by getting regular checkups. This provides assurance that your dental health gets monitored regularly and thus prevents any problems that may arise.
  • Plan with your dentist to get the most out of your coverage. This way you also minimize out-of-pocket costs.
  • In applicable situations, delay any work that will result to an excess of allowed yearly benefits. For example, if work that is scheduled on November will get you over your year's limits, consider delaying it to next year when a new set of limits become applicable to you.
  • Use pre-authorization to your advantage. This is especially true with treatments that come with high costs. When the insurance company requires you to get pre-authorized, you get to know beforehand how much you will be paying out-of-pocket for a particular procedure.
  • Know where to ask answers and get a fast response. This is very helpful during emergencies.
  • Check if your plan follows the LEAT approach or the Least Expensive Alternative Treatment approach. If it does you may not be covered for certain treatments recommended by your dentist.

Standard steps to filing a dental insurance claim

  1. First, present a dental plan claim form. This is done in two instances, when services have been availed of or when there is a need for pre-authorization prior to receiving service.
  2. The claim document covers the following information:
    • The full name as well as the address of the individual filing the claim
    • SS number
    • The patient's name and date of birth
    • The group name and number
  3. Supporting documents should go along with the claim. These would cover receipts, itemized bills with information on the patient like his name, identification number, the name and address of the dentist, dates services were rendered, ADA (American Dental Association) procedure codes, description of the treatment provided, and the corresponding charge.
  4. Copy of the Explanation of Benefits should be attached.
  5. Dental insurance form should be properly signed and dated.
  6. These documents should be submitted by the dentist to the insurance company either by mail or via electronic submission.

How to dispute a denied claim

  • Go over the EOB and look for the explanation on the matter you want to dispute. Know why the claim was denied.
  • Get in touch with the insurance company and seek an explanation.
  • Put your complaints in writing. Provide the necessary documents to back up your arguments such as your dental records and a letter from the dentist. Forward your letter and the supporting documents to the address provided in the letter denying your claim.
  • If the company stands firm with the decision, you may elevate the matter to the next level. Usually, dental insurance providers offer their clients two levels where you can appeal before a set of reviewers.
  • You can also bring the matter before the insurance commissioner in your state or before the Employee Benefits Security Administration if the plan you have is under ERISA laws. For further information, go to http://www.dol.gov/dol/topic/health-plans/erisa.htm.

Choosing a dentist

The American Dental Association provides the following guide when selecting your dentist:

  • Ask for recommendations from friends, family, coworkers or your own family doctor.
  • When moving to a different place, ask for a recommendation from your current dentist.
  • The dental society in your state or community may also offer you recommendations.
  • Visit more than one dentist before making a decision.
  • Check the clinic hours of those in your list, see if they are convenient for you.
  • Is the clinic accessible to you?
  • Check the dentist's education and training.
  • Ask what his or her approach is to preventive dentistry.
  • Find out if he or she regularly attends conferences and workshops.
  • Ask what are the procedures and arrangements for emergencies that may happen outside of clinic hours.
  • Ask how much will certain procedures cost like x-rays, cleaning, filling a cavity, oral examination.
  • Is the dentist a participant in your dental plan?
  • Check out the dentist's clinic and see if it is orderly, neat, if the equipment is clean. See how the staff handles your questions and observe how the dentist performs actual treatments.
Have a question about insurance? Ask the experts
Share: