Insurance can be a confusing subject, and dental insurance is no different. With so many different companies and policies in the market, it can be difficult to know just how your policy works and what it covers. Employers can even have different policies within the same business. Just because you have a policy doesn’t mean your co-worker has the same policy. These are some common misconceptions we’ve seen from patients regarding dental insurance. The following information is not true for all policies but are the most common issues we see among a variety of insurance companies.
• Cleanings are NOT FREE!!! The cost for cleanings does come off your annual maximum benefits.
• If you have had a filling or crown done your insurance will not pay to have the procedure
done again for a specific amount of time. Fillings are a payable benefit 1 time in a 2 year
period. Crown are a payable benefit 1 time in 7-10 years. It does not matter the reason for
needing to be replaced it is never a covered benefit outside these specifics.
• If you are having teeth extracted we usually recommend a healing partial or denture. This is
a prosthetic that is worn until the patient’s tissue is completely healed, usually for 6-9 months. After that healing period, a final difinitive partial or denture is placed. Many insurance policies will only pay for a crown, partial, or denture one time in a period of 7 – 10 years. What this means is that you may not want to bill the insurance company for the healing denture, or they will not pay for the final denture 9 months later.
• Bleaching and Veneers are considered cosmetic and almost never covered.
• Fluoride treatments can sometimes be the most preventive treatments and insurance companies only pay for 1 treatment per year til the age of 15. So not all preventive services are covered at 100%.
• If you have a concern of how much you will be reimbursed we can do a Pre-Determination of
Benefits. We will submit the procedure codes that you to have done and the amount we charge and the insurance company will let us know the amount they will pay. Do not be fooled, THIS IS NOT A GUARANTEE OF BENEFITS!!!
• If you have any questions regarding your policy call the customer service number on the
back of your insurance card to get current and accurate information.
Questions to Ask Your Insurance Company
These are some questions that we recommend everyone with dental insurance ask their insurer. Many details of dental insurance policies can be difficult to find in the technical language of the policy itself, and may not be clearly spelled out in any paperwork. Sometimes, the only way to find out is to ask.
1. What is my calendar maximum for the year?
2. Does my calendar maximum run from January to December, or from my effective date?
3. What is my calendar deductible each year? Individual or family?
4. Is my plan a PPO or DMO?
5. What is my coverage breakdown on preventative, basic, and major services?
6. Do I have a waiting period on basic or major services? If so, how long?
7. What are the time limitations on Panorex x-rays, Full Mouth x-rays, and bitewing x-rays?
8. Can I schedule my cleaning appointment twice a year, or does it have to be 6 months to the day to have this benefit paid?
9. Does my pan have a “missing tooth clause” in effect?
10. What is my group number, mailing address for DENTAL claims, and customer service number?
11. Does my plan cover implants or implant crowns?
12. Does my plan cover sealants for my children? If so, what is the age limit?
In the end, it is up to each of us to become experts in our own insurance coverage and act as our own advocates to maximize the value of the benefits we pay for. Hopefully some of these tips and ideas will help you get the most out of your dental insurance policy.