Navigating coverage and reimbursement for your dental care doesn’t have to be a headache. The problem is, for most, their dental plan is a “black box”. Specifically, they go to the Dentist, and don’t know what to expect when they get to the front desk for billing. There are 5 really simple things that you can find out about your insurance coverage. This will eliminate stress and frustration for you. Further, knowing these things will help you get the most out of dental care!
Key Dental Insurance Plan Details
- Yearly Maximum. Most plans have a maximum amount of coverage per year. For some the maximum is $1000. For others the maximum is $3500. Occasionally, a dental plan will not have a yearly maximum. It’s really easy to find out what your maximum yearly coverage is. In fact, most employers will give you a booklet outlining your benefits details. Write the number down and remember it – it’s really important!
- Interval Period. For most dental insurance plans, the yearly maximum is according to the calendar year (January 1st to December 31st). In other cases, the interval period is set according to when you started working for your employer. Specifically, a person who starts with a new employer in April might have an interval period from April 1st to March 31st. Again, this is super important to know so check with your benefit provider.
- Covered Expenses. The insurance world categorizes dental treatment as either BASIC or MAJOR. Basic care typically includes cleanings, fillings, root canal treatments and extractions. In contrast, major care includes crowns, bridges, dentures and other prosthetic treatments. Some plans cover only basic expenses. Others will cover both. It’s critical to know how comprehensive your plan is!
- Reimbursement Percentage. Reimbursement rates differ for BASIC dental expenses and MAJOR dental expenses. The most common reimbursement rate for basic expenses is 80%. The most common reimbursement rate for major expenses is 50%. However, plans differ and so it makes good sense to find out these 2 numbers from your provider.
- Direct Billing Support. Most dental plan providers support direct billing. This means that your Family Dentist can bill your provider and collect funds from them directly. If there is a co-payment or deductible to be collected from the patient, they pay only that at their appointment. This arrangement allows you to avoid paying entire treatment costs out-of-pocket. There are still dental plan providers that require patients to submit claim forms for reimbursement. Specifically, a patient pays the entire treatment cost up front and then collects reimbursement from their plan provider later. Unfortunately, you can’t change this but it helps to know if you will be paying large amounts out-of-pocket at your appointments. You will also want to confirm that your Dentist can provide Direct Billing as some clinics do not.
Knowing a few key details about your dental insurance coverage can make your life easier. You can also ask your Dentist to send pre-determinations to your provider. A pre-determination allows your provider to evaluate a possible claim or expense and notify you about coverage in advance of treatment. Your plan provider may take up to 4-6 weeks to give you a response. In cases where immediate treatment is required, you might not have the luxury of waiting for a pre-determination response. In these cases, it is especially critical to know the basic details surrounding your coverage.
Thank you for reading. I hope you have found this article helpful!
By Dr. Kyle Hornby, Family Dentist in Kitchener
This article is intended to promote understanding of and knowledge about general oral health topics. It is not intended to be a substitute for professional advice, diagnosis or treatment. Always seek the advice of your dentist or other qualified healthcare provider with any questions you may have regarding a dental condition or treatment.