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HOW DOES MY INSURANCE PLAN WORK?

Your Dental Insurance is a contract between your employer and the insurance company. It is the plan purchaser, such as your union or employer, who determines what is covered when they purchase your plan, not your dentist. It is your responsibility to know your plan coverage, including any changes. Please ask your benefits administrator or insurance provider for a plan booklet or information on your specific coverage. In particular, please be aware of: 

  • Plan limits: Does your plan have a yearly maximum based on a fixed dollar limit (i.e. $700 total coverage) or the frequency of services provided (i.e. units of scaling, or recall exams)? What is the plan year (i.e. a calendar year or a specified 12 months)?

  • Percentage of coverage: What percentage of each treatment is covered at? For example, many standard dental plans will cover 80 percent for preventive dental services (exam, X-rays, cleanings, fillings) and 50 percent for major dental services (crowns, bridges, veneers, dentures and etc.) It is rare for a plan to cover 100 percent of services.

  • Fees covered for each procedure: Dental plans reimburse based on the plans fee schedule; this may differ from the fee your dentist charges. For example, if your plan's schedule is $100 for a particular procedure (pays 80 percent of this fee) but your dentist charges $120 for the same procedure your dental plan will still only cover 80 percent of $100, or $80. You will need to pay any remaining costs, in this case $40.

  • The co-payment: This is the portion of the plan that you are responsible for paying. For example, if your plan covers 80 percent of a procedure, you are responsible for the remaining 20 percent. You are responsible for any costs not covered by your plan. Any portion of the price not covered by your plan must be paid by you (the same as the deductible on your car or home insurance). The claim form submitted to your insurance company is a contract. Your dentist has an ethical and legal obligation to collect the co-payment from you.

  • Lab fees: As part of your treatment your dentist may work with an outside lab. The lab sets its fees independently of the dental office; lab services may or may not be covered.

  • Dual coverage: You may be eligible for additional coverage if you are also covered under a spouse/partner's dental plan. In this case your dental plan provides the primary coverage while your spouse or partner's plan may provide some additional support. However, this may not apply if the two plans are with the same company.

A predetermination of benefits is a great tool for you to understand the benefits available and estimated out-of-pocket expenses. But there is no guarantee of payment, and all provisions such as limitations and exclusions are NOT applied to the predetermination. Please read the fine print/disclaimer on the predetermination carefully to understand the result. For example, you may have implant coverage and the predetermination may state the plan benefits for implants, but when the actual claim is processed, a limitation such as an alternate benefit of a removable partial denture may be applied to the implants. This results in a higher out of pocket expense for you. 

Your treatment plan will be provided according to your needs, not your insurance coverage. If needed, we can help you understand your coverage and assist you in getting pre-determinations for treatment. However, please keep in mind that our staffs are not experts on your plan. Dental insurance companies will never notify us of any changes to your dental plan. 

We are also willing to directly bill to your insurance for you, as your plan permits. Nonetheless, some plans do not allow for direct billing and you will be liable to pay your portion or amount the day of service.

 

Insurance Agent
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