What are Dental Insurance Plans?
Despite its name, dental insurance is not a true form of insurance, but instead is a contractual arrangement between insurance companies and participating dentists in which dentists agree to perform discounted contracted rates for dental work in exchange for a client or patient pool. This agreement is more like a coupon or discount plan for the customer, as there many terms and restrictions as to when and if they can use it. Comparing it to home, auto or even health insurance you are not fully covered against major problems related to your dental health. The focus of dental insurance companies is to only fully cover preventive services (like cleanings and x-rays) because these are the least costly for them, allowing them to keep more of the premiums paid and keep their executives and shareholders happy.
How Insurance Works
The amenities and terms these discount plans offer are purposely vague and not transparent for patients and dentists alike, giving them the freedom to pick and choose what is covered, how much of it is covered and when it is covered. For example, do you know much your deductible is? What is your annual maximum? Do you have a “pre-existing condition” that would cause them to deny you the care you need? If you don’t know the answers, you are not alone. Most plans only give you a $1000-2000 per year but only access to that once you’ve paid the deductible ranging from $50-200. So, once you’ve paid the deductible on top of what you already paid to sign up for the plan then on top of the copay you paid to go to a “in-network dentist”, anything outside of preventative care will be covered at a percentage of what the insurance company deems appropriate for your health. Minor procedures like fillings may be covered at 80% of the contracted fees while major work like crowns, bridges or dentures can be covered at 50% or not at all. We can assume if something major happened to our home or car, we wouldn’t want to hear it will only be fixed at 50% of the cost. Why should our dental insurance be any different?
The determination for your health is done by claims reviewers who are dentists working for the company who have never seen you or know your complete medical or dental history. For example are in dire tooth pain needing a root canal, going through your dental insurance will require submitting x-rays and documentation to them, waiting weeks to hear back and finally receiving a notice that the procedure “is not medically necessary” all while you are in pain the dentist is restricted to what they can do to manage your condition. They will, however, cover more for an extraction incentivizing you to lose your tooth because it kept more of your premium for their profits as it costs them less for that than a root canal.
In the situation above, you may already not be eligible for any coverage if you have not met their waiting period which can range from 6 months to years. This means if you or your employer has just enrolled in a plan you would have to wait that long before anything other than routine cleanings and exams would be covered but again only after you’ve paid the deductible and any copays required. Employers will often sign you up for the most basic plans which would require you to pay more for more coverage. Within this time or even after your “insurance” will not cover anything related to pre-existing conditions (existing issues or treatment you had done prior to signing up for the plan). For the example above, if you paid out of pocket to have the root canal done, then got dental insurance to help pay for the crown or filling needed after it, it could be deemed a pre-existing condition and not eligible for any coverage.
The other issue even after getting coverage is the annual maximums and coverage/frequency limitations. The annual maximum coverage amounts of $1000-2000 have been about the same since the inception of dental insurance in 1950, more than 70 years ago. Rising costs for you the patient, has not caused these companies to even think about raising the amount they cover over this period of time. Even if you do what is fully covered, the fees for the exam, x-rays and cleanings can take up close to half of your maximum leaving you with only a little left to cover any unexpected events. They will also only procedures a certain number of times. Your plan most likely will cover 2 cleanings per year, a full set of x-rays every 5 years and some removable or fixed options once a lifetime. If you have a genetic condition that makes your gums unhealthy and requires more cleanings per, it will not matter as your insurance company has set 2 as the limit. Lost your dentures unexpectedly? You will have to wait up to 7 years for them to pay for a new one.
Utilizing Insurance at Dental Restoration Pros
We are considered “out-of-network” by insurance companies, as we are not involved in any contractual agreements with insurance companies. We have opted for this because we do not want to be restricted in how we are able to offer you care, and don’t have to work within set parameters for you. For you the patient, this is an option to be free to choose who you want to see for your dental needs instead of picking a name off of a list. It allows you to have control over the care you need, without having to worry about “doing only what insurance covers.”
Insurance companies often will offer “out-of-network” benefits to their members, but it will depend on the type of insurance you have. The two main types are PPO plans and HMO plans. HMO plans are more restrictive and may not offer these benefits, but they also force you to see an assigned dentist who has agreed to see you for a set reimbursement. More and more dental offices are not accepting these plans and only go in-network with PPO plans. If you have a PPO insurance, you will usually be eligible to see out-of-network dentists and be reimbursed a significant portion, 50% or more, of the treatment directly to you.
To utilize any insurance benefits you may have, you will have to pay for the service at the time its rendered. After paying, we will assist you in filling out a claims form in addition to giving you any documentation, narrative and x-rays needed. This is then submitted to your insurance company who will reimburse you directly according to your unique policy.
If you don’t have insurance and are worried about costs, we have packages available which are better than insurance coverage. The pro package we offer gives you 10% off all dental treatment at our already very affordable costs, unlimited cleanings and complimentary emergency exams so you can truly be prepared for routine and unexpected care.
Dental insurance poses challenges due to low annual coverage limits and restrictions on the frequency of covered procedures. Annual maximums have remained stagnant for over 70 years, leaving little room for unexpected expenses, and many treatments are limited in frequency, potentially causing issues for those with unique dental needs. This raises questions about the true nature of dental insurance as a reliable financial safeguard.