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Simply put, dental insurance covers dental treatments. It’s much easier to navigate than medical insurance. Its purpose is to offset the cost of dental care. The focus is on preventative measures and helping patients maintain good oral health. Treating illnesses as soon as symptoms arise to prevent more complex issues is the main idea. In cases of more severe problems, dental insurance usually covers at least a portion of the treatment, so the patient doesn’t have to pay the full bill.
Dental insurance is a valuable benefit covering preventative care at 100% and lowering out-of-pocket costs. Although it is separate from medical insurance, many employers offer it as part of their benefit package (in addition with vision insurance). Dental insurance can therefore be a part of a larger medical insurance plan or a separate policy. 3 out 4 Americans have dental insurance, but many do not know how it works or what it covers. Let us help you understand the basics.
What does dental insurance cover?
Let’s take an exemplary coverage structure of 100-80-50. Here’s what it means:
- Routine exams and regular cleanings (preventive care) is covered at 100%
- Basics treatments such as fillings, some root canals, tooth extractions, treatments for gum disease are covered at 80%
- Major procedures involving crowns, dentures, bridges (or other prostheses) are covered at 50%
It’s important to note that a deductible, or the amount you must pay before the insurance coverage begins, may apply to these services, especially basic and major treatments. Diagnostic and preventive services are usually free for most insurance providers.
How about things not covered by insurance? Here’s a few examples:
- Select procedures: while this varies from plan to plan, some dental insurance providers do not cover certain treatments or procedures like orthodontics.
- Cosmetic procedures such as teeth whitening, teeth shaping, gum contouring, and veneers may not be covered by dental plans. Why? Because they are meant to improve your look and while being medically unnecessary.
- Certain pre-existing conditions like missing teeth may also not be covered by some policies.
Since not all dental plans are the same, it is always best to check with your provider. You can also inquire with your dentists’ office about the treatments that are covered vs. those that are not.
Terms to know
There may be certain terms you come across while reading up on your dental insurance. Below we explain some of the most popular ones:
- Coinsurance/Copay: A share of payment for a specific service the patient is responsible for.
- Deductible: Minimum payment you’re responsible for before the insurance provider pays anything. If you have a plan that covers regular check-ups, your deductible would begin with any restorative work. Once you meet your deductible, your insurance pays the pre-established percentage of all future bills.
- Dual coverage: When you have more than one dental plan either through your spouse, another job, parents or other means. Dual coverage does not mean double coverage or paying more than 100% of expenses. It does, however, reduce the overall out-of-pocket costs.
- In-network dentist: These are the dentists who accept your insurance plan. It means they have agreed to accept a pre-established cost for specific services. Visiting an in-network dentist is cheaper than seeing an out-of-network provider.
- Waiting period: It’s the time before your eligibility to receive benefits for full or partial treatment begins.
- Annual maximum: This is the total amount of money your insurer will pay for your coverage during one year. What does that mean? For example, if your annual maximum is $1,500 – you are responsible to pay for all additional costs once your dental insurance pays $1,500 for your treatments. Good news is that usually only up to 4% of Americans exceed their annual maximums.
The Cost of Dental Insurance
The cost of your monthly premium (or insurance payment) will depend on several factors:
- Your insurance provider
- Your location
- Your chosen plan (HMO, PPO etc.)
The cost of a monthly premium is, on average, $50. So, even if you’re not using your insurance benefits, you pay $600 every year for your dental plan.
If you know that you will need more complex treatment and costlier procedures, such as dental implants, you’ll need to check your coverage with your provider to learn more about your cost. Many basic insurance plans don’t cover implants, or, if they do, there are limitations and exclusions.
How to pay for a procedure
To ensure you don’t pay too much for your procedure, it’s important to follow a few simple guidelines:
- Read your dental policy closely to check if your treatment is covered or not. Still not sure? Go ahead and give your insurance company a call. They’ll be able to answer your questions.
- If you’re in need of a major procedure, ask your dentist for a pre-treatment estimate. That way you’ll be able to figure out how much money you’ll still owe once deductible, coinsurance and policy maximum are all met.
Affordable Care Act
The Affordable Care Act, more commonly known as Obamacare, states that pediatric dental care is an essential health benefit. It can either be a part of a larger medical insurance plan or a separate policy. Dental insurance coverage for adults is not required under the ACA.
Contact Smile in Michigan Today!
Whenever you have questions about your insurance coverage, treatment costs or estimates, call our office. We are here to help you! Don’t forget to use your dental insurance and schedule your regular check up visit today!