Understanding Dental Insurance

The entire team at Eckland Family Dentistry is committed to insuring our patients receive the best possible dental care. Therefore, we are committed to support you in understanding your dental benefits so that you will always be able to make decisions you feel comfortable with. As a courtesy, we will process your insurance benefits in our office, which will relieve you of this time consuming and sometimes-complicated task.

What You Need to Know about Dental Insurance

If you’re like most people, you may sometimes take your dental health for granted. Foregoing regular dental care can not only have serious health consequences, it can also be a bad financial decision. According to a 2019 survey by the National Association of Dental Plans, approximately 47% of adults participate in employer-sponsored dental insurance plans but many, in turn, don’t make use of this benefit. Less than half of insured adults actually use their dental insurance and a mere 4.2% reach their annual maximum. With the average annual cost of dental insurance for an individual at about $360 a year, it just makes sense to get the most out of that investment. To help you better understand dental insurance and dental benefits plans, we’ve pulled together some essential information you should know.

If you don’t use it, you will lose it.

Health insurance is both expensive and confusing which causes many of us to simply adopt an avoidance strategy when it comes to understanding the details. Dental insurance is a different animal altogether, so it pays to understand the differences.

Dental benefits versus insurance.

Dental insurance doesn’t work like other insurance types. An insurance plan is set up to cover a loss and the insurer carries the risk. So, your homeowner’s insurance will reimburse you if you lose your home to a fire or natural disaster and if you total your vehicle, your car insurance pays you the value of your car.

Dental coverage is set up as a benefit plan—it will cover certain costs up to a maximum amount. For example, free preventative care (exams, cleanings, and X-rays), $1,500 to $2,000 annually for restorative procedures (fillings, crowns, etc.) and a $1,500 to $ 2,000-lifetime benefit for orthodontics are typical maximum thresholds. It’s even possible that some procedures won’t be covered at all by your dental benefits plan. The vast majority of dental plans are based on care delivered within a calendar year. What you don’t use in that year, you lose. Also, dental insurance deductibles tend to be quite low, often under $100, which makes this less of a deterrent than comparable health insurance plans.

What does dental insurance cover?

In the majority of cases, while many dental benefits cover preventative care (two cleanings and two dental exams per year), most won’t cover other services because they are designed around annual maximum benefits vs. a cost-of-care model. When you sign up for dental insurance, be sure to understand what is covered by your benefits and what you will be responsible for. Here are some of the terms you might see:

  • Deductibles: This is the amount you will have to pay before your plan will begin to pay. Typically, there is no deductible to meet when you get preventative or diagnostic services but be sure to verify what your plan covers.
  • Annual maximums: Your plan will only pay up to a certain limit each year. Therefore, if you have dental expenses of $2,500 in a plan year, but your plan covers $2,000, you would have to pay out of pocket for the $500 difference. This is also after you had paid for any deductible.
  • Coinsurance: Coinsurance is the percentage of the charges that you are responsible for paying. For example, a 60/40 plan would mean your benefits provider would handle 60% of the charges for a service and you would pay the remaining 40%.
  • Least expensive alternative treatment (LEAT): Some plans have a LEAT clause. If yours does, this means if there is more than one option for treatment, the plan will cover the least expensive one.
  • Pre-existing conditions: It’s important to understand how pre-existing conditions are handled by your dental benefits plan.

In most cases, dental benefits plans will require you or your provider to submit a treatment plan for prior authorization before any services are completed. If you have any concern that a procedure might not be covered, it’s always a good idea to run it by your plan’s administrator who will review the treatment proposal, determine the patient’s eligibility for the procedure, the co-payment that will be required, and the max amount to be covered.

Types of dental plans.

When trying to understand dental insurance plan, it’s easy to get discouraged by all the acronyms that fly around. PPO to DHMO can leave you with FOMO (fear of missing out) on what might be a better plan and exclaiming OMG! Never fear, we have an alternative.

10 Facts to Know about Dental Insurance

At Eckland Family Dentistry, we know that rising healthcare costs are no small matter. That’s why we want to help all our patients get the most out of their benefits and why we continually stress the importance of preventative dental care to help avoid oral health conditions that can be both painful and costly. That’s also why we accept most dental insurance benefits, accept credit cards for payment, and offer flexible financing terms and our Eckland Family Dental Plan for patients without insurance.

There’s a lot to think about when it comes to understanding dental insurance. You can count on us to advise you regarding what we know about your plan or what you should consider when understanding your treatment options. Here are some facts about dental insurance we have learned:

  • FACT #1: Dental Insurance is not normal insurance, it is a prepaid benefit plan. As such, it is not a pay-all solution. It is more like a band aid. It is like a coupon that can be used at different dental offices.
  • FACT #2: Many dental plans tell their insured that they will be covered at 80% or 100%. In spite of what you have been told, most plans cover about 40-60% of an average fee. Some plans pay more, some less. Benefit levels are determined by the amount your employer paid for the plan. The less the employer paid, the less you will receive in dental benefits.
  • FACT #3: Insurance companies tell their customers that “fees are above the usual and customary fees,” What they mean is we don’t cover that. Remember, you get back in benefits only what your employer puts in less the profits of the insurance company.
  • FACT #4: Many routine dental services are NOT covered by dental insurance.
  • FACT #5: Insurance companies will often “downgrade” a procedure in order to pay less. A common example is when an insurance company will only cover an amalgam (Silver and Mercury) as opposed to more modern natural tooth colored composites. This would be like using grass thatch on your roof. Remember, we want to provide you with the BEST dentistry, your insurance wants the CHEAPEST.
  • FACT #6: The people who review insurance claims and treatment plans often lack any dental training. They have never seen or examined you, they don’t know your medical or dental history and the certainly don’t know what’s best for you. We don’t assume we do either. Our commitment is to insure you have all the information you need to make decisions you are comfortable with.
  • FACT #7: Your insurance company will sometimes try and encourage you to see a “Preferred Provider.” These dentists are “preferred” by the insurance company because they have agreed to lower fees in exchange for more patients. While this economic principle makes sense on factory lines and bulk buying, it does not make sense in a service and healthcare environment. To get the best care available you need to select a provider who works for you, not who reports to an insurance company. At Eckland family dentistry we will not cut corners or reduce the quality of the care we provide .
  • FACT #8: Dental Insurance started in the 1960’s with $1,000 worth of benefits. If this kept up with inflation, dental benefit maximums would be $8,500. The 2020 the average maximum benefit is $1,250.
  • FACT #9: Dental Insurance is the opposite of insurance. The term insurance means that one is insured against a catastrophe. Once a deductible is met, insurance pays the remaining balance. Dental insurance is the exact opposite. Dental Insurance only pays up to a certain point, your maximum, then you are responsible for 100% of the remainder.
  • FACT #10: There are 3 parties involved in your oral health – You, Your Dentist, and Your Insurance Company. Insurance companies do not care about your health or your teeth. Example, they will pay 50% of procedures needed to save an abscessed tooth (Root Canal, Build-up & Crown). Yet, they will pay 80% to extract the tooth. They incentivize the patient to have their tooth removed. It is one less tooth for them to “insure.”