TOOTH TALK: Dental insurance basics

Dr. Igor Kaplansky

The cost of dental care is of increasing concern for families, and a quick internet search will yield dozens of companies vying to sell you dental insurance at too-good-to-be-true prices. It’s important to understand these types of policies and especially their limitations. Be sure to investigate your options before signing a contract.

According to the Academy of General Dentistry, dental insurance plans are either indemnity (fee-for-service) or managed care plans. Typically, indemnity plans: offer a greater choice of dentists and pay their share of costs after receiving a bill. Managed care plans — dental PPOs, POSs and dental HMOs — have agreements with certain dentists to provide a range of services to members at a reduced cost. Usually members have less paperwork and lower out-of-pocket costs.

Every plan has a yearly maximum, the most money that the dental insurance plan will pay within one full year. The maximum, which averages $1,000, will automatically renew every year. Generally, if you have unused benefits, these will not roll over.

Find out if your plan will cover your dentist. Most independent dental insurance plans will only pay for services if you go to a contracted and participating in-network dentist. If the plan requires that, get a list of dentists in their plan and see if you are comfortable with one of them. Your own dentist’s website will generally show the plans they have contracted with.

In general, dental insurance companies use what is called a Usual, Customary and Reasonable (UCR) fee guide. The companies set their own price that they will allow for every dental procedure that they cover. For example, your dentist may charge $80 for a cleaning; and if your insurer's UCR fee is $60, you're left with a $20 out-of-pocket expense.

For insurance companies, dental procedures are generally broken down into three categories, each raising the price of dental coverage.

The first category is Preventative. Routine cleanings and examinations are generally considered preventative dental care. X-rays, sealants and fluoride may be classed as preventative or basic, depending upon the specific insurance carrier.

The second category is Basic or Restorative. These treatments usually consist of simple extractions and dental fillings. Root canals can be considered basic or major and many insurance plans have them in the basic category.

The Major category includes costly procedures like crowns, bridges, dentures, partials, surgical extractions and dental implants. Some plans do not cover these procedures at all.

Every dental insurance carrier has different categories and qualifications, so it is important to clarify which dental procedures fall under each specific category. Also know that some plans have waiting periods for certain procedures. That is the length of time an insurance company will make you wait after you are covered before they will pay for a procedure. For example, if you need a crown and the policy has a 12-month or longer waiting period, there’s a good chance you could have already paid for your crown while you have been paying your premiums and waiting.

Believe it or not, more than 90 percent of dental insurance policies carry a “missing tooth clause” and/or a “replacement clause.” 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. If you’ve lost a tooth while you had no coverage, they won’t pay to replace it after you sign up. 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 and you have paid the required premiums.

Keep in mind that 99.9 percent of dental insurance companies won’t pay for cosmetic dentistry, that is, any type of procedure done for vanity purposes only. These days, everybody wants their teeth whitened!

Before deciding on dental insurance, speak with your dentist. Since each case is unique, he or she knows what treatment plan would be best for you, and will be able to offer alternative solutions if necessary. You may decide you are better off without dental insurance at all. Most dentists accept credit cards or will arrange in-house financing for extensive procedures. Also, many dentists have private plans with an annual fee, which offer discounts through the year on services for those who are self-employed or have no insurance.