More often then not, dental insurance is a huge factor when it comes to one deciding if they would like to have their dental treatment done or not. However, until it is time, most people are completely unaware what their dental insurance covers, what it doesn’t, and to some extent — some are unclear on who their dental insurance carrier even is! This not uncommon at all. I’m sure we can all remember signing up with our employer’s dental plan, receiving a huge packet of information, and setting it right on the dining room table. Not exactly something one feels like picking up and reading on a day off.

If you were to open up that booklet, what’s inside is an enormous list of dental procedures. It lists what the procedure is and the percentage of that procedure that your plan will cover. When patients come into our office, one of the most commonly used phrases about insurance is: “I don’t understand what kind of coverage I have.” This, in our opinion, is exactly how the insurance company likes it.

The first misconception about dental insurance is that it is just like medical coverage. With medical coverage, when something is wrong, you go to the doctor or the hospital, and everything is normally taken care of. This is not the case with dental insurance at all. What most don’t realize is that every dental insurance has what they call an “Annual Maximum.” An annual maximum is the amount of coverage your policy will cover a year. Most dental insurances allow an annual maximum of about $1,000-$1,500. These annual maximums have not been changed now for about 20-30 years. Obviously, the cost of dental treatment has gone up from 20 years ago, so realistically, this does not cover much if one needs more than a cleaning or a cavity. The typical cost for major work, like a crown (cap) could range anywhere from $900-$1,300. That, right there, would drain most of your benefits for the year, and most are unaware that this annual maximum is even in place!

Percentages are another tactic that insurance companies use to make it look like they are paying for most of your work. However, what they typically don’t tell you is that these percentages are based off of what is call “Customary, Usual and Reasonable Fees.” This are known as UCR fees. What this means is that a dental insurance company has a set fee for every procedure. Again, these fees have not been updated for many years, so while dental offices continue to raise their fees as the years go by, dental insurances still only cover the same amount they did over 10 years ago. Funny how that works, isn’t it?

In and out of network is another issue that can be confusing at times. One often wonders: “What’s the difference?” Well, there isn’t really much of a difference. If your dental insurance is a PPO, then like medical insurance, it means that you can see whichever provider you choose — there is no list. However, if your insurance is an HMO or a DMO, then there is a specific list that you must choose from in order to have your dental work covered. That being said, there are many things that HMO and DMO plans do not cover, some of which are very basic procedures. A PPO plan is a little bit better, but again, there are still some relatively basic procedures that are not covered by these as well.

Let’s go back to UCR fees though, since this is a very hot topic. When an office is considered “In Network” with your insurance, they have been contracted to charge a certain cost for a procedure. This means that they have decided that they are going to chage the UCR fee according to your insurance, so they are essentially charging you what it would have cost to get the same procedure done over 10 years ago. Out of network offices are allowed to charge what the procedure costs today. However, the insurance will only reimburse based off of their UCR fee.

For example, let’s say that a cavity costs $150. Insurance says that they will cover 80% of a cavity based off of their UCR fee, which is $100. So you will receive $80 as a reimbursement. This is actually very generous of an insurance company, since UCR fees are not normally that high. That $80 is deducted from your annual maximum, so imagine if you need major work like a crown, bridge, or even dentures. The even worse thing about dental insurance is that 99.9% of them say that if you are missing a tooth prior to having their insurance, they will not cover replacing that tooth/teeth.

So there are a ton of questions that you should ask when you are thinking about signing up for dental insurance. First, ask what the annual maximum for the plan is. Second, figure out if they have a “Missing Tooth Clause” incase you are thinking of replacing teeth that you are missing. Finally, really sit down and think about if it is even worth it for you, financially, to get dental insurance. Most times, when someone needs work done, they end up paying more for their coverage than for what they actually get back from it. Here at Dr. Silva’s office, we have no problem answering any dental insurance questions you may have!

Also, many dental offices, including Advanced Dentistry of Collegeville, offer several different payment plans to make dental work affordable, some of which are even interest free! So for those things that insurance will not cover, or when you run out of your annual maximum, there are still options at your fingertips to get your work done!

The most important thing is that you do not let your insurance dictate the care you should receive. If you need something, you NEED it. A doctor knows more than an insurance company. Holding off on the small things your insurance doesn’t cover only leads to large things that they also won’t cover.