It’s not uncommon to have a hard time understanding your dental insurance. Not only is each plan different, but there might be terminology that you don’t know. To top it off, you might not understand why some procedures are covered at one percentage while other are covered at a much higher or lower percentage. While we cannot possibly know every detail about every insurance company or policy available, here are some facts that might help you decipher your plan.
Deductibles: When Do They Apply?
A deductible in dental insurance terms means about the same as it means in medical insurance terms. It’s the fee that you need to pay before the insurance company begins paying for work. Some policies apply the deductible toward preventative work and others do not. Some policies don’t have deductibles, but the ones that do usually apply them per calendar year.
Unlike medical insurance, many dental insurance plans include a yearly maximum of benefits paid. This means that if your maximum is, for example, $1,500, that is the amount that your insurance will pay out over the course of a calendar year. There are certain procedures that might not apply toward the maximum; these often include cleanings and periodic exams. Some policies do count these, however. There are a few plans that do not have calendar year maximums.
Coinsurance and Copays
If you have a dental HMO, you will pay a copay per procedure in most cases. This means that if you have a two-surface resin filling, you’ll pay a set fee regardless of the actual charge for the filling. (Do keep in mind that this only applies if you see an in-network dentist.)
If you have a dental PPO or another type of plan, most of the time you will pay a percentage of the cost. Common coinsurance percentages are 20 percent for things like fillings and 50 percent for things like crowns. This varies substantially depending on the plan. Also, if you go to an out-of-network dentist, you will, in most cases, pay more because the dentist won’t usually accept the insurance’s reduced fee plan as payment in full. If your dentist doesn’t participate with your insurance plan, it’s a good idea to find out what they charge for a procedure and to find out from the insurance company what they will pay.
Dental insurance can be confusing, and we can help you make sense of your plan. Do keep in mind, however, that it’s your responsibility to know the details of your plan. Call your insurance company for specific information or ask our front desk for help understanding your plan.