How Does Individual Dental Insurance Work
How does dental insurance work? By and large, dental insurance plans are pretty straightforward, and with a little information anyone can understand them. In fact, Id bet my two front teeth I can explain how health insurance works in under five minutes. Shall we try? Heres everything you need to know about how dental insurance works.
How Much Do I Have To Pay
That will all depend on the plan you choose.
There are many variations so its always important to know your plan details.
Some plans set annual deductibles, limit plan spending, cap dollar amounts, and limit the number of visits allowed in a benefit year.
Dental plans often do not cover every dental procedure, however, for the basics including regular check-ups, x-rays, hygiene , fillings, root canals and extractions will usually be partially paid out.
The ratio for insurance payments in minor procedures is typically 80% -20%.
This means that an insurer is likely to pay about 80% of the treatment costs according to their own fee guide, leaving the 20 % an out of pocket expense for the patient.
For treatment deemed major, such as crowns and bridges the ratio is more likely to be 50% 50% of the insurers fees.
It is important to understand that the majority of dental clinics may be using their own fees for procedures and not the ones set by your insurance company, resulting in a higher co-payment for the patient.
Your Dental Clinic can also provide you with a predetermination of costs.
A predetermination is a request sent to your insurer asking for coverage and estimated reimbursement details.
This gives the patient an idea of what will be covered and what will be out of pocket.
Can my dentist waive my co-payment?
No. Any waiving of patient portions is insurance fraud and is against the law.
What is Direct Billing?
Your Dentists Role
Does Health Insurance Cover Dental Care
As mentioned, dental insurance is typically offered in three ways:
- As part of an employer-sponsored health plan
- As part of a health plan you buy yourself, such as through or a broker like eHealth
- As a stand-alone dental plan or rider
Not all healthplans cover dental benefits, and availability will vary depending on where youlive. Under healthcare law, dental benefits arent an essential health benefitfor adults. This means that health insurance companies arent required to offerdental coverage if youre over 18 years old. If youre interested in finding ahealth plan that includes dental coverage, or if youd like help finding astand-alone dental plan, eHealths plan findertool makes it easy to browse and compare prices and benefits across plans.
Please note that while insurance companies arent required to offer adult dental insurance, dental benefits are considered an essential health benefit for children. So, if your health plan covers dependents 18 and younger, the plan is required by law to have dental benefits available as part of its health coverage, or to provide these benefits as a separate dental plan. However, health care law only requires that dental benefits be offered to children youre not required to buy it.
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Can I Buy Dental Insurance Without Health Insurance
Yes, you can buy dental insurance without health insurance. When you purchase a health insurance plan, it doesnt automatically include dental coverage. Dental insurance is separate from health insurance.
Unlike health insurance, you can buy dental insurance anytime of the year and from any insurance provider. You do not have to buy health insurance and dental insurance from the same insurance company. Make sure that the dental insurance plan you choose has the coverage and benefits that you and your family need.
Choosing The Right Dental Plan
Behind every great smile is a dental plan that helps to improve the oral health of the people it covers. But before you choose your dental insurance, its important to understand the way a plan is structured, what it covers, and the value it provides for the cost. Whether youre planning for braces, or just want to stay on track with cleanings, knowing how dental insurance works will help you choose the right plan for your familys needs and budget.
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Typical Dental Insurance Coverage
According to the National Association of Dental Plans , roughly 77% or 249.1 million Americans have some form of dental insurance. This may be through your employer or through other group programs. A dental benefit plan is set up to cover certain costs. The dental plan may cover some procedures fully, it may cover a percentage on other procedures, and you may find that some recommended procedures are not covered at all.
According to Consumer Reports, the most common dental plan coverage through your employer is a 100/80/50 plan :
- Diagnostic and preventative procedures are covered at 100%. This would include cleanings, exams, and films. Typically, cleanings and exams are covered twice per benefit year.
- Basic procedures are covered at 80%. This would include fillings, simple extractions, and some periodontal work. These may be subjected to waiting periods, frequency limitations and or deductibles.
- Major procedures are covered at 50%. This would include difficult procedures such as crowns or bridges. These may be subjected to waiting periods, frequency limitations, and or deductibles.
Although this is typical dental insurance coverage, we urge all our patients to contact their human resources department or their insurance provider to better explain your dental benefits to you.
Please note that this out of pocket cost may be subject to change
Dental Insurance For Dummies
When your medical or dental insurance sends you an explanation of benefits in the mail, do you throw it unopened on a pile of paperwork that includes the deferment paperwork for your student loans from 1962? Or are you thinking “What the heck is an explanation of benefits?” If you do open it, does it hit you like a Rorschach Inkblot test? You think there is something important you are supposed to be able to see, but you can’t quite figure it out. When you ask your HR person at work to explain the basics of the group dental plan does he or she say “It covers some stuff” or “We have a group dental plan?”
Compared to your medical plan, your group dental plan is a cinch. Here is what you need to know:
1) Deductible – Typically $25 or $50. This is applied and paid by you when you have your first appointment for dental treatment like a filling or crown. Most plans do not apply this deductible toward your exams and cleanings, therefore no money is due from you during these types of appointments.
2) An annual maximum benefit – This is typically $1000.00 – $1500.00. Most plans are calendar year. When the insurance has paid benefits up to this amount you are cut off until next plan year. On January 1st of the next year your maximum is available to you again.
3) The annual maximum benefit is paid out in percentages depending on the type of service you have at the dentist. Typically:
Type 3 services 50% coverage – crowns, build ups, posts, dentures, bridge work.
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Buying Individual Dental Insurance
There are a couple of different ways buy a dental insurance plan. How this works depends on the type of coverage you need and how you purchase your insurance.
Health benefits exchange: Many dental insurance carriers offer plans through a health benefits exchange. In Washington State, we have the Washington Health Benefit Exchange . These plans are designed to meet the needs of families with varying budgets.Currently, dental insurance plans can only be purchased through the exchange along with a medical insurance plan.Standalone plans: A good number of dental insurance carriers also offer standalone insurance plans. These are purchased directly through the insurance carrier. These are purchased directly through the insurance carrier. In this case, you can buy a dental insurance plan even if you have no health insurance.
The Insurance Company Likes You Better
An insurance company will reimburse you, as the patient, faster than it will reimburse the dental practice. YOU are their customer, after all, NOT the practice. So if you are in a situation where you have to pay the provider in full, the insurance company will reimburse you directly. Now withelectronic submissions, the reimbursement can happen within 2-4 weeks.
Even though we recommend you verify your own benefits, a reputable practice will help you figure this out. We will submit your insurance paperwork, and give you an instruction sheet on the next steps to submit or receive reimbursement. Our practice guides the patient through the insurance process until the reimbursement happens, and we are happy to help you with any claim issues along the way.
If youve been told you need a dental work, contact us at 704-243-1122 for an evaluation, as early as possible. Our office will break down that coverage for you so you can get an idea of what you have to use toward treatment.
- Waxhaw Dental Center
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How Do You Apply For Dental Insurance
There are a couple of ways you can get dental insurance:
- Your employer may offer you dental coverage as part of your employment benefits. If so, you can apply for that during annual open enrollment. There may be different types of dental plans you can choose from that can help cover the type of dental care you expect to need.
- If your employer doesnt offer dental insurance, or if you lose a job or work for yourself, you can buy a dental plan on your own. You can do this either through a state health exchange or directly from a health insurance company like Cigna.
Primary And Secondary Insurances:
Imagine the workflow Ive discussed so far, and now think about doing it TWICE once for EACH insurance the patient has!
Normally my process for PreAuth for dual insurances is this:
Lets say a patient needs two crowns. Normally I dont send out predeterminations for crowns, but if theres a slight doubt in my mind about whether or not the insurance will pay for it I want to create a narrative report along with intra-oral photos and send it along with a predetermination to get it preapproved before I do any work on the patient.
So lets say a patient needs two crowns and they have two insurance Primary is Delta and secondary is MetLife.
So my process is this:
Send the predetermination for the two crowns to Delta first. Wait for the result, and then take the predetermination EOB from the Delta and send it to the secondary .
Wait again for the approval from MetLife. Once I receive the approval from the secondary, Ill review both EOBs with my front desk.
Total of expected payments from both plans should equal the primarys allowed amount for the procedure.
Ill get into details on how to deal with dual insurances in another post.
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How Dental Insurance Categorizes And Pays For Procedures
Dental procedures covered by insurance policies are typically grouped into three categories of coverage: preventive, basic, and major. Most dental plans cover 100% of preventive care, such as annual or semiannual office visits for cleaning, X-rays, and sealants.
Basic procedures are treatment for gum disease, extractions, fillings, and root canals, with deductibles, co-pays, and coinsurance determining the patients out-of-pocket expenses. Most policies cover 80% of these procedures, with patients paying the remainder. Major procedures such as crowns, bridges, inlays, and dentures are typically only covered at 50%, with the patient paying more out-of-pocket expenses than other procedures.
Every policy differs in which procedures are categorized as preventive, basic, and major, so it is important to understand what is covered when comparing policies. Some policies classify root canals as major procedures, while others treat them as basic procedures and cover much more of the cost.
Patients who may need costlier procedures should pay particular attention to the details of dental insurance policies. For instance, a single dental implant can cost $3,000 to $6,000. Many basic dental insurance plans don’t cover implants, and those that do come with limits and exclusions. With that in mind, many consumers choose dental insurance that will cover implants.
We Know Dental Insurance Terms Can Be Tricky To Understand We’ve Put Together This Handy Guide To Help You Understand Your Dental Insurance Coverage
Getting a handle on your dental insurance is step #1 to guarantee you get the maximum benefit from your dental coverage.
- Read and review the benefits booklet for the fully detailed outline of all that is included in your dental benefits.
- Register/sign in to your MySmile® account and click on Coverage overview for an easy-to-read overview of your plan’s features and benefits.
- Benefit period
- Reimbursement levels
- Waiting period
To help you better understand these fundamentals of your dental coverage, here’s a brief explanation of each one:
Benefit PeriodEssentially, a benefit period is the length of time during which the benefit is paid. Your dental coverage has both a plan effective date, and an end date, and in most cases, the benefit period for your plan will be one year.So, if your effective date on your plan is January 1, 2020, and the end date is December 31, 2020, you will no longer have coverage as of December 31, 2020, unless you renew your plan before the end date.
These two terms may sound similar, but they are not exactly the same. Both are fees that the patient is responsible to pay for a portion of their dental treatments.
MaximumYour dental plan probably mentions two types of maximums: annual and lifetime.
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You Can Also Buy Standalone Health Coverage
Some types of coverage can be purchased as standalone plans. For example, if your plan doesnt include travel, catastrophic drug coverage or hospital coverage, you can buy these as standalone plans. Catastrophic drug coverage offers unlimited drug coverage once youve paid a certain amount in annual drug expenses, while hospital coverage provides for a semi-private or private room if youre hospitalized.
The Basics Of Dental Insurance
Dental insurance gives you coverage to help pay for certain dental work. These policies can help insured parties pay for all or part of the work their dentists perform, from routine cleanings and X-rays to more-complicated ones such as implants.
Although dental insurance works a little like health insurance, the premiums are typically much lowerbut, of course, theres a catch. Most health insurance policies cover a hefty percentage of even towering expenses once youve paid your deductible, and many have an annual out-of-pocket maximum, along with a $50 to $100 deductible. This is not the case with dental insurance, which usually follows a 100-80-50 coverage structure.
If you are using in-network dentists, dental plans generally pay 100% of preventive careexams, X-rays, and cleanings. Basic procedures, however, such as fillings, root canals, and extractions, only pay 80%, while major procedures such as crowns, bridges, implants, and gum-disease treatment may only be 50% of the cost. Orthodontia and cosmetic dentistry, which are not deemed medically necessary treatments, are usually not covered at all. This means you may still have to pay a hefty price to get your work done.
Dental policies range from group insurance to individual and family plans, and they come in three categories.
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Understanding Your Dental Insurance
Do you have dental insurance? Do you understand exactly how it works and what it covers? Sure, dental insurance is a huge benefit since it saves you a lot of money. You can protect your teeth and smile at a fraction of the price youd pay without dental insurance. Still, coverage is often confusing. You need to know what you can and cant do on your current plan. Heres a guide to understanding your dental insurance.
Dental Insurance Training Course
The Dental Insurance for Financial Coordinator Course is a self-paced online course.
Students taking this course consist of dentists, front office management staff, financial coordinators, and those new to the dental field.
This course will guide you in accurate and efficient claim filing methods, treatment planning, ways to educate patients on their insurance coverage, as well as implementing financial policies and office-wide protocols which will increase overall production of the dental practice. An overview of different types of policies, coding, alternative benefits and managing patient treatment is discussed as well.
All course material is provided. Questions may be asked from our instructors via email, telephone or our forum.
This self-paced training is offered in the Diploma Program as a 4-week course and for CE credit, upon passing, of 10 hours for dental professionals satisfying continuing education requirements for licensure. Regardless of how much time is spent on the course, no more than 10 CE credits will be extended. However, you may choose to access the material for study or review during the entire 4-week duration of the online course. Revised 2019
Continuous support will be provided to each of our students after the completion of their course at no additional fee.
Grading PolicyOverall assessment for this course is based on quizzes, exercises and the final test.
Questions and Answers of Everyday Situations
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Dental Insurance Does Not Cover Cosmetic Procedures
Most dental insurance policies do not cover any costs for cosmetic procedures, such as teeth whitening, tooth shaping, veneers, and gum contouring. Because these procedures are intended to simply improve the look of your teeth, they are not considered medically necessary and must be paid for entirely by the patient.Some policies cover braces, but those usually require paying for a special rider and/or delaying braces for a lengthy waiting period.