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Q. Dental Insurance – Should you Purchase Dental Insurance?

Facts to Consider Before Buying Dental Insurance

The yearly maximum is the most money that the dental insurance plan will pay within one full year. The yearly maximum will automatically renew every year.

If you have unused benefits, these will not roll over. Most dental insurance companies allow an average yearly maximum of $1,000.

In/Out of Network Dentists

Most independent dental insurance plans will only pay for your dental services if you go to a contracted and participating In-Network Dentist. Find out if you are required to go to a participating dentist or if you can choose your own. If the plan requires that you see an In-Network Dentist, ask for a list of the dentists in your area with whom they are contracted so you can decide if they have a dentist you would consider seeing.

If you wish to stay with your current dentist, some policies allow you to see an Out-of-Network Dentist, however, the costs covered may be significantly lowered.

UCR (Usual Customary and Reasonable)

Almost all dental insurance companies use what is called a Usual, Customary and Reasonable (UCR) fee guide. This means that they set their own price that they will allow for every dental procedure that they cover. This is not based on what a dentist actually charges, but what the dental insurance company wishes to cover. For example, your dentist may charge $78 for a dental cleaning, but your insurance company will only allow $58 because that is the UCR fee that they have set.

If you are on a policy that requires you to go to a participating provider, you should not be charged the difference between these two prices. A contracted dentist generally has an agreement with the insurance company to write off the difference in charges. If the policy allows you to go to a dentist of your choice, check the insurance company’s UCR fee guide against the fees that dentist charges. You may be required to pay the difference out of your pocket, however, you cannot put a price tag on quality dental care.

Dental Insurance Coverage Types

According to most dental insurance companies, dental procedures are broken down into three categories:

1. PreventativeMost insurance companies consider routine cleanings and examinations as preventative dental care, however, X-rays, sealants and fluoride can be deemed as preventative or basic, depending upon the specific insurance carrier.
2. Basic or RestorativeBasic or restorative dental treatment usually consists of fillings and simple extractions. Root canals can be considered basic or major. However, the majority of dental plans list root canals as basic.
3. MajorCrowns, bridges, dentures, partials, surgical extractions and dental implants are dental procedures that most dental insurance companies consider as a major procedure.

Since all dental insurance carriers are different, it is important to clarify which dental procedures fall under each specific category. This is important because some insurance plans don’t cover major procedures and others have waiting periods for certain procedures. If you know that you will need major dental work that is not covered by a given plan, you should probably look elsewhere to find one that suits all of your needs.

Dental Insurance Waiting Periods

A waiting period is the length of time an insurance company will make you wait after you are covered before they will pay for certain procedures. For instance, if you need a crown and the policy has a 12 month or longer waiting period, chances are you could have already paid for your crown while you have been paying your premiums and waiting.

Missing Tooth Clause and Replacement Period

More than 90 percent of dental insurance policies carry a “missing tooth clause” or a “replacement clause.” Many include at least one of these clauses, but most have both. A missing tooth clause protects the insurance company from paying for the replacement of a tooth that was missing before the policy was in effect. For example, if you lost a tooth before your coverage started and later decided that you would like to have a partial, bridge or implant, the insurance company would not have to pay for that service if they have a missing tooth clause in the plan. A replacement clause is similar except that the insurance company won’t pay to replace procedures such as dentures, partials or bridges until the specified time limit has passed.

Cosmetic Dentistry and Dental Insurance

Cosmetic dentistry is any type of procedure done for vanity purposes only. Teeth whitening is very popular. While the effects are gorgeous, keep in mind that 99.9 percent of dental insurance companies won’t pay for cosmetic dentistry.

Comprehensive Coverage

Before deciding to purchase dental insurance, talk with your dentist regarding the extent of your treatment plan. This way you can decide if you would be better off with or without dental insurance. A very important factor to remember regarding any dental insurance plan is that dental insurance is not at all similar to medical insurance.

The majority of dental insurance plans are designed with the purpose of only covering the basic dental care around $1,000 to $1,500 (about the same amount that they covered 30 years ago) per year and is not intended to provide comprehensive coverage like that of medical insurance.

Dental Insurance Summary

To help finance your dental care, many dental offices are now offering interest-free payment plans because they understand that dental insurance only pays a small portion.

If you decide that purchasing dental insurance is the best choice for you or your family, these tips should help you choose the right dental insurance plan.

Q.  What Are Dental Insurance Coverage Types?

A. According to most dental insurance companies, dental procedures are broken down into three categories:

1. PreventativeMost insurance companies consider routine cleanings and examinations as preventative dental care, however, X-rays, sealants and fluoride can be deemed as preventative or basic, depending upon the specific insurance carrier.
2. Basic or RestorativeBasic or restorative dental treatment usually consists of fillings and simple extractions. Root canals can be considered basic or major. However, the majority of dental plans list root canals as basic.
3. Major Crowns, bridges, dentures,  partials, surgical extractions and dental implants are dental procedures that most dental insurance companies consider as a major procedure.

Since all dental insurance carriers are different, it is important to clarify which dental procedures fall under each specific category.

This is important because some insurance plans don’t cover major procedures and others have waiting periods for certain procedures. If you know that you will need major dental work that is not covered by a given plan, you should probably look elsewhere to find one that suits all of your needs.

Q. Dental Insurance – What is Usual, Customary and Reasonable?

A. Almost all dental insurance companies use what is called a “usual, customary and reasonable” (UCR) fee guide. This means that they set their own price that they will allow for every dental procedure that they cover. This is not based on what a dentist actually charges, but what the dental insurance company wishes to cover. For example, your dentist may charge $78 for a dental cleaning, but your insurance company will only allow $58 because that is the UCR fee that they have set.

If you are on a dental insurance policy that requires you to go to a participating provider, you should not be charged the difference between these two prices. A contracted dentist generally has an agreement with the dental insurance company to write off the difference in charges.

If the policy allows you to go to a dentist of your choice, check the insurance company’s UCR fee guide against the fees that dentist charges. You may be required to pay the difference out of your pocket, however, you cannot put a price tag on quality dental care.

Q. What is Direct Reimbursement?

A. A direct reimbursement plan is a dental insurance plan that is usually entirely funded by your employer and allows you to choose any dentist without the hassle of networks.

With a direct reimbursement plan, you are reimbursed for money spent on dental work, which is not limited to specific treatments. Some employers may choose to reimburse you after you have paid for your dental work, and some may choose to pay the dentist directly — leaving you with less out-of-pocket expense.

The Benefits of a Direct Reimbursement Plan:

• You can choose any dentist.
• There are no monthly premiums to pay.
• There are usually no deductibles.
• Pre-authorization is not required.
• You can calculate your portion accurately from the treatment plan given to you by your dentist, with no hidden costs.
• A direct reimbursement dental insurance plan does not have waiting periods. For example, many traditional plans have a clause that says you have to be covered for a certain amount time before they will pay for root canals, crowns and other major services.
• There are no missing tooth exclusions.
• Payment is generally allowed for any type of dental procedure. Some direct reimbursement plans even cover cosmetic services, such as teeth whitening.

How it Works

As with a traditional dental insurance plan, a direct reimbursement dental insurance plan usually has a maximum yearly allowance. This means that the plan will only pay for a certain amount of dental work each year. The average yearly allowance for any type of dental plan is around $1,000 to 1,500.

A common direct reimbursement plan would pay for 100% of the first $100 spent on dental services; 80% of the next $500; and 50% of the next $1,000.

Choosing a dental insurance plan is an important decision and understanding the different types of dental insurance plans available will make this process easier.

Q. Dental Insurance – What is a Yearly Maximum?

A. The yearly maximum is the most money a dental insurance plan will pay out within one full year. A yearly maximum could run on a calendar year (January to December), or on a fiscal year, depending on the dental insurance company.

The yearly maximum will automatically renew every year. If you have unused benefits, these will not roll over. Most dental insurance companies allow an average yearly maximum of $1,000.