It can be hard to understand how insurance works, dental insurance included.
Many of our patients at Dentistry at 1818 Market Street come to us with dental insurance. So we want to make sure our patients understand their dental insurance benefits and how to use them.
At Dentistry at 1818 Market Street, a dentist in center city Philadelphia, we see patients regardless of whether they have dental insurance or not. You can choose to use dental insurance at our dental office, or, if you don’t have insurance, you can pay for your services, which is referred to as fee-for-service, or FFS.
Dental insurance helps you manage the cost of dental care so you can maintain your overall good health.
Most dental insurance covers preventive care, which includes regular checkups by your dentist, and may also cover care for cavities, implants or getting a tooth knocked out.
Like other types of health coverage, dental plan benefits vary by plan and insurance company. For more detail on coverage, always check the plan benefits documents for the plan you’re considering. In general, a dental insurance policy will typically cover:
- Regular checkups and cleanings, usually twice a year (out-of-pocket copay may be required)
- Cavity fillings
- Tooth extractions
- X-rays
- Crowns, bridges, and implants
- Root canals and other necessary repair work
- Dental appliances (e.g.., retainers)
- Emergency dental procedures, such as oral surgery
Please note that certain dental equipment or services may be covered, but at different levels of coverage.
Typically, preventive care, such as cleanings, is covered fully, while other procedures, such as fillings or emergency oral surgery, may have higher out-of-pocket costs. You may be responsible for paying a deductible before coverage will kick in for these types of procedures. This is usually waived for preventive care.
Most dental insurance plans follow the 100/80/50 payment structure: They pay 100% for preventive care, 80% for basic procedures, and 50% for major 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 treatments for gum disease, extractions, fillings, and root canals, with deductibles, copays, and coinsurance determining the patient’s 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 for other procedures.
Every policy differs in terms of 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.
Dental insurance works a lot like health insurance.
Each month you pay a premium (a set dollar amount) and when you visit the dentist, you may be responsible to pay a copay, if your plan includes copays. The dentist’s office will bill the insurance company directly for your care. Most preventive dental care visits, which often cover checkups and cleanings, are covered under your dental insurance plan. Your insurance company will pay the dentist directly for your preventive care visits while you are only responsible for your copay, if your plan includes copays.
If you have a dental procedure that is not considered preventive care, the dentist’s office will send your insurance company a bill and, depending on your plan, your dental provider will bill you for the portion of the procedure your insurance company did not cover. You can find which procedures are covered by reviewing your plan details.
Like health insurance, there are a variety of dental insurance plans that offer a range of coverage options. Depending on your family’s needs and your budget, there are several affordable dental options available for you to choose. To calculate the cost of dental insurance for you and your family, first identify your specific needs and then choose a plan that meets those needs.
Before enrolling in any dental coverage, be sure to read the fine print to make sure you understand what you’ll be responsible for paying out of pocket, what’s covered versus what’s not, and what your deductible will be. You can save money by only buying what you need; stand-alone policies can be customizable to suit your needs and budget.
When you’re ready to schedule your next dental visit, reach out to our center city dental office to schedule your dentist appointment. We can take your dental insurance information over the phone and give you an estimate of what you can expect your appointment to cost at our philly dentist location.
- Do you have children that need regular, preventive care?
- Will you or your children need orthodontic care?
- Does anyone in your family require care for dental issues?
- Are you or your family members in need of crowns or similar procedures?
- Have you been to the dentist in the last year?
- Do you visit your dentist on a regular basis?
- Do you have any medical conditions such as diabetes or hypertension?
Dental plans typically fall into one of three categories: employer-based, self-purchased, or “riders” attached to medical insurance policies. Whether you currently have coverage or are trying to decide whether to add on dental benefits, it’s important to understand the basics of dental insurance, which we’ll be discussing below.
Here are 9 fundamentals of your dental insurance that you’ll want to know and understand:
- Benefit period
- Co-payments/coinsurance
- Dental network
- Deductibles
- Maximums
- Reimbursement levels
- Waiting period
- Preventative Care
- Out-of-Pocket Costs
To help you better understand these fundamentals of your dental coverage, here’s a brief explanation of each one:
Benefit Period
Essentially, 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, 2023, and the end date is December 31, 2023, you will no longer have coverage as of December 31, 2023, unless you renew your plan before the end date.
Co-Payments/Coinsurance
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.
Some dental plans include a co-payment, which is usually a flat fee per visit / treatment, and does not generally count towards your deductible.
Coinsurance is the amount (usually a percentage) the patient is responsible to pay for a specific dental treatment, after the insurance company has paid their portion. For example, if your plan specifies you have a 20% coinsurance for fillings or crowns, then your insurance will pay 80% of the cost billed by the dentist, and you will be billed the remaining 20% for those services.
Deductible
Similar to your homeowner or auto insurance policies, the dental plan deductible is simply the amount that you must pay out of pocket, before the insurance policy pays for any treatments. For example, if the deductible is $200, and the covered individual’s procedure is $179, the insurance does not kick in and the individual pays the entire amount. Most dental plans do have annual deductibles. Some are for each individual covered on the plan and some will be one deductible for all family members included in the plan.
Some plans do not have a deductible required for some of the basic preventive treatments and services such as annual check-ups, cleanings, X-rays, etc.
Review your specific dental plan coverage to determine what deductibles you are responsible for.
Maximum
Your dental plan probably mentions two types of maximums: annual and lifetime.
The annual maximum is simply the maximum amount your plan will pay toward the cost of all your dental care within that benefit period, which is usually the calendar year. When patients reach the yearly maximum, they must pay for 100% of any remaining dental procedures. Many plans do not count standard preventive and diagnostic treatments toward the annual maximum. The annual maximum is important to consider, especially if it applies to more than one family member. Some plans will allow you to tap into your annual maximum’s value if you do not spend it all in one year. Some dental plans, for example, will allow you to roll over portions of your annual maximum that you do not use to the next year as long as you complete your preventive screenings. That can come in handy in the event you need major dental work.
The lifetime maximum is the maximum dollar amount your plan will ever pay toward the cost of specific dental services. The most common dental services with lifetime maximums are orthodontic treatment and TMJ.
Since not all plans are created equal, and some will have an annual or lifetime maximum, while others will not. This is why it is essential to read and become familiar with your specific plan coverage and limits.
Reimbursement Level
Dental insurance plans generally cover different treatments and services at different percentages (a.k.a reimbursement levels). The various types of services are categorized into 3 main classes with different reimbursement levels for each class. There are also some exclusions or restrictions noted for each class as well.
Here are the 3 main classes, and the reimbursement levels that generally apply to each class*:
Class I procedures are preventive and diagnostic. They are covered at the highest percentage (usually 100%). This enables patients to obtain the routine, preventive treatments to help avoid more costly, and complicated treatments down the road.
Class II includes basic restorative procedures like root canals, fillings, and extractions. These services are reimbursed at a lower percentage than Class I services. For example, 70-80% reimbursement vs. 100% for Class I.
Class III is for major restorative procedures such as inlays, on-lays, crowns, and dentures. These services are typically reimbursed at the lowest percentage and may have a waiting period before these services are covered by your plan.
*Note: As with all aspects of your dental insurance coverage, it is important to review your specific plan benefits to confirm these reimbursement levels.
Waiting Period
In some cases, a plan will require a waiting period prior to allowing coverage for a specific treatment. Dental plans are usually set up to discourage people from using them only for emergencies or major procedures. That’s why most plans will place waiting periods on certain service types.
For example, suppose your plan has a 4 month waiting period for root canals. If your plan coverage began on January 1, then your waiting period ends on May 1. Anytime after May 1, you are eligible to use your benefits for this treatment. Some dental plans have no waiting period.
Preventive care
Dental plans feature many different options, but the one thing nearly all of them emphasize is preventive care. Dental insurance is designed to make it easier for you to prevent serious oral health conditions like tooth decay and gingivitis..
Your dental insurance should allow you at least one preventive cleaning per year, usually two. In addition to cleanings, consider whether the plan offers:
- X-rays
- Routine oral exam
- Sealants
- Fluoride treatments
Out-of-pocket costs
Here are some of the out-of-pocket costs you may encounter with dental coverage:
Deductibles. As discussed above, some dental plans include a deductible that you must meet before dental coverage will kick in. Others, such as dental indemnity plans, will require you to pay up front for services and then submit for partial reimbursement later.
Copays. Find out if your dental plan requires you to pay a certain amount out of pocket each time you visit the dentist.
Coinsurance. Some plans will begin to partially cover the cost of services after a deductible has been met. The coinsurance amount will vary based on the dental service performed.
Cosmetic procedures. Find out which procedures your dental plan will not cover because they are considered cosmetic. For instance, some dental plans consider certain types of crowns cosmetic.
Pre-treatment estimates
If you anticipate the need for major dental work, or just want to get an idea on service pricing, contact our office and we can provide you with a cost estimate. This can help you get an idea of how much money different procedures will 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.
Costs and what procedures are required may also differ based on the patient’s age. Seniors on Medicare, for instance, will have a different dental insurance needs than someone in their early thirties.
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 meant 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.
Do note that while insurance companies aren’t required to offer adult dental insurance, dental benefits are considered an essential health benefit for children. So, if your health insurance 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, you’re not required to buy it.
