Breaking Down Dental Insurance

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In order to understand what will be or what WILL NOT be covered by your dental insurance plan, you must understand some of the jargon and/or guidelines.  These guidelines can vary from one insurance to another as well as from one company’s dental insurance plan to another depending on what was included in the plan from the start.

In Network:  Your dentist or dental office participates in that particular insurance plan, it’s like being a member of a club, their name is on the list.

Out of Network:  Your dentist/dental office DOES NOT participate in the plan, NOT a member of the club, NOT on the list

Usual & Customary (U&C):  All charges are considered by your insurance/insurance companies have certain limitations of the amount they will cover for a particular procedure.   For instance the doctor’s office charges $100.00 for a cleaning, but insurance only allows $80.00 for the same procedure.  Their payment is $80.00.   You are responsible for the $20.00 balance.

Deductible:  This is the amount your dental coverage requires before they will begin making payment(s) toward certain procedures.  Deductibles vary depending on the plan.  (Most companies do not have a deductible amount attached to preventive procedures,i.e. cleaning, routine examination).

Coverage:  List of procedures the insurance will pay toward, usually split into 3 or 4 categories, they are as follows:

  • Preventive – cleanings, fluoride, regular checkups, sealants
  • Basic – Fillings, non-surgical extractions
  • Major – Crowns/veneers, implants

Percentage of coverage:  Once again this amount will vary from plan to plan and from procedure to procedure, however, most plans percentage of coverage breakdowns goes like this:

  • Preventive at 100%
  • Basic at 50%
  • Major at 50%

However, you must keep in mind the other factors of in network or out of network and U & C, and deductible.

Explanation of Benefits (EOB):  Usually the piece of paper you will receive from your insurance carrier showing what was or was not paid and why.

Pre-Estimate:  This is the dental claim file PRIOR to having work done.  The dental office can file this for you before you come back and you should receive the EOB within 3-4 weeks from your dental insurance carrier

Wondering if you should get a second dental insurance?  Well, this can be a little tricky.  You must keep in mind the same rules apply, Coverage, percentage of coverage, U&C, in or out of network, and deductible.

Most insurance coverage which falls into the 2nd position will consider what the 1st insurance carrier has paid.  Also the 2nd carrier will not make their payment toward ANY procedure regardless of their coverage until they have received the EOB from the 1st carrier.

For example:  If the 1st insurance paid ¾ of the charges it is not a guarantee the 2nd insurance will pay the remaining amount.  In many instances I have seen where the 2nd insurance paid nothing.  As they put in their EOB “Our payment amount was based on the Primary insurance, therefore, our payment amount was “$0.00”.

So in theory you’re paying them and they’re paying nothing because they fall into the 2nd position and after their calculations, they felt the 1st carrier paid enough on that particular bill, and the balance is your responsibility.  (I have yet to figure out the secret squirrel formula of how the 2nd insurance calculates their payments).

I personally feel a 2nd dental insurance carrier is ONLY useful in cases where the patient has a substantial amount of dental procedures to be performed.  Otherwise you will just be giving the 2nd insurance carrier money to burn and in these times, I don’t think any of us want to do that!

ADVICE:  When in doubt of any insurance coverage for any procedures, have the dental office file a pre-estimate so that you will have an idea of what will be covered and at how much.



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