TOOTH TALK: Is dental insurance necessary?

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. Whether you are thinking of purchasing insurance through your employer or on your own, investigate your options before signing a contract.

According to the Academy of General Dentistry, “Dental insurance plans usually are described as either indemnity (fee-for-service) or managed care. Indemnity and managed care plans differ in their basic approach. The major differences concern choice of providers, out-of-pocket costs for covered services, and how bills are paid.

"Usually, indemnity plans offer a greater choice of dentists than managed care plans. Indemnity plans pay their share of the costs of a service only after they receive a bill. Managed care plans have agreements with certain dentists to give a range of services to plan members at reduced cost.

"In general, you will have less paperwork and lower out-of-pocket costs if you select a managed care-type plan and a broader choice of dentists if you select an indemnity-type plan. Managed care plans are dental PPOs, POSs, and dental HMOs. Some dentists, called non-participating or insurance-free dentists, do not accept any insurance in their practice.”

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

Find out if your plan will cover your personal dentist. Most independent plans will only pay for your dental services if you go to a contracted and participating in-network dentist. If that's the case, get a list of dentists in the 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; it's not based on what a dentist actually charges, but what the dental insurance company wants to cover. For example, your dentist may charge $80 for a dental cleaning, but the insurance company will only allow $60, because that is their set UCR fee. That leaves you with a $20 out-of-pocket expense.

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

The first category is preventative. Routine cleanings and examinations are generally considered preventative dental care. However, 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. Such 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 such as crowns, bridges, dentures, partials, surgical extractions and dental implants.

Every dental insurance carrier has different categories and qualifications, so it is important to clarify which dental procedures fall under each specific category. Some insurance plans don't cover major procedures at all and others have waiting periods for certain procedures. If a plan doesn’t cover your specific needs, look elsewhere.

A waiting period is the length of time an insurance company will make you wait after you are covered before they will pay for certain procedures. For example, if you need a crown and the policy has a 12-month or longer waiting period after starting the policy, there’s a good chance you could have already paid for your crown while you were 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.

Cosmetic dentistry is considered to be any type of procedure done for vanity purposes only. These days, everybody wants their teeth whitened. The blinding smile may boost your morale, but keep in mind that 99.9 percent of dental insurance companies won’t pay for cosmetic dentistry.

Before deciding on dental insurance, the best step you can take is to speak with your personal 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. Most dentists accept credit cards or will arrange in-house financing for extensive procedures.

 

If there is a topic you would like discussed in this column, email your request to gasportdentist@gmail.com.

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