While most employers offer dental insurance to their employees, many people do not utilize these benefits to their full potential. It’s almost like signing up for a gym membership but only going once every few months. Here are a few pointers to help you maximize your dental insurance benefits.
Your dental insurance is structured in a way to help the insurance company to save money in the long term. Like many things in life, it is much easier to prevent a problem before it happens.
This is one reason that most dental insurance companies pay for 100% of your preventive care, which means you will not have to pay anything out of pocket. Preventive care will include procedures such as exams, x-rays and cleanings, and fluoride for children.
There are other preventive procedures that are commonly covered at 100%, such as dental sealants. These are a thin tooth-colored layer put on the biting surface of the adult molars to help fill in the pits and grooves. Sealants lower the risk of your child getting cavities in the future. Getting a sealant is a painless and fast procedure that can be done at the same time as the cleaning. Make sure you ask your dentist about dental sealant for your child at their next appointment.
If you can’t prevent a dental problem, it’s important to stop it at an early stage. Many insurance companies will cover fillings at 80% - 100% while larger, more complex procedures may only be covered at 50%.
For example, if you have 80% coverage and a filling is normally $120, you will be paying only $20 out of pocket. But let's say the cavity got larger and turned into a pediatric crown costing $240. But the crown is only covered at 50% so your out-of-pocket is now $120. Even though the crown did cost twice as much as the filling, your out-of-pocket is 6 times higher!
Please note that opting for a filling when a crown is a better treatment option will not save you money in the long run. If you under treat the tooth and the restoration fails, your child will not only have to deal with additional procedures, but you will end up having to pay for a filling and then a crown after the filling fails.
Typically, a deductible (usually $50-100) will need to be paid when you first need treatment in a coverage year. This fee is separate from your co-pay and is only paid once a year if your child needs restorative work but not preventative work.
You can help pay fewer deductibles by getting all your child’s treatment done in one year and still going to all their preventive treatment the following year. If your child does not need restorative work like a filling or crown in the second year, you will not have to pay that deductible again. If you spread out the treatment between two years you will have to pay the deductible for each year.
Every dental insurance plan I have encountered has an annual limit of either $1,000, $1,500, or $2,000 per child per year. The insurance company will only pay for treatment (including preventative care) up to this amount each year.
The extra money not spent from this limit does not carry over to the next year, Any unused benefits are lost. Typically these benefits will restart at the start of a new calendar year.
This is useful information for children who need extensive dental work, such as if your child needs $2,000 worth of dental work but your annual maximum is $1,000. If this is split into two appointments (one in December and one in January) at $1000 for each appointment, you would maximize the use of your insurance and pay the least out of pocket cost.
In this situation, you would be paying a deductible each year, but you would be paying a $50 additional deductible compared to paying an additional $1,000 in non-covered services.
Please note I am not suggesting deliberately pushing treatment if it is not in the best interest of the patient. If your child is in pain, the teeth will most likely get much worse by spreading out these appointments. Please get your child dental treatment as soon as possible.
A health saving account is not insurance, but many employers do provide this option to their employees. In these accounts, you are able to put pretax dollars in. Depending on your income level, this could save you money.
For example, if you are in the 25% income tax bracket and you need to pay for $600 worth of treatment, you could pay $600 from your HSA or you would have to earn $800 to have $600 after taxes. In this case, you will save $200.
The main downside I have seen with an HSA account is that additional documentation is needed to prove that the money was spent on medical or dental expenses and in some cases, unused money left in the HSA account is lost after a specific amount of time. Please speak with your employer and HR department about restrictions you might have on your HSA account.
When a patient has two insurance plans, they typically assume that anything not covered by one plan will be covered by the other. This is typically not accurate.
When an insurance claim is submitted, there are specific dental codes based on the procedure that was done. One of the insurance companies will be set as the primary while the other will set as the secondary.
The claim will be sent to the primary first for payment. Any copay or deductible will still need to be paid. The second insurance company will not cover your copay or deductibles. The only time the secondary will pay for things that the first did not pay for is for a specific dental code or if you reach your annual maximum.
The claim will then be submitted to the second insurance company for payment. If the code was not paid for by the primary insurance company, the secondary will be for that code if it is covered under the policy.
Sounds complicated right? I suggest keeping things simple.
If you have two working parents in the home and your employer is paying for both of your dental insurance there is no problem. If at least one of you is paying a portion of your wages to pay for dental insurance in most cases you will not get your money’s worth.
If you do have two working parents who are each paying for their own dental plan through their work, I would suggest canceling and putting those savings into an HSA account to be used to help pay for treatment.
If you already know that your child needs extensive work or specific procedures such as orthodontics, it would be good to look into a dental plan with better coverage for these services.
First, let's define what “in-network” actually means. When a health care provider is in-network with an insurance provider, it means that they have agreed to a lower fee schedule for their services. The difference between the office original fees and the agreed fee will be processed as an insurance adjuster.
Why would a good dentist agree to these lower fees? Being In-network is an effective way to attract patients. But due to the lower reimbursement rates from the insurance companies, many dentists are forced to make appointments shorter so that they can still cover their overhead and other expenses.
In many cases, your employer determines which company you have your insurance plan with. For some insurance companies, little to no in-network provides for the specific insurance carrier. You might be able to speak with your employer and switch which company they are using to provide their insurance. This could possibly not cost the employer any more money but will help save money at your next dental appointment.
Please note you can still use your private dental insurance with most dental offices. The only difference is your copay will be higher.
Most dental patients assume their insurance will cover two cleaning and exams in a year. This is a little inaccurate. What they typically do is cover a cleaning and exam every 6 months. This might seem like the same thing but with some important differences.
In order to have your cleaning paid for you need to have not had cleaning within the past six months. This clock for your next cleaning will start until after the last cleaning was done. This means that if you go to the dentist every 8 months, you will be only getting 3 cleanings and not 4 over a two-year time period. But you will still be paying the same monthly premium for fewer services.
Another limitation you can run into is if a restoration needs to be replaced. For example, if a filling was done and 3 years later new decay forms on a different portion of the tooth. In many cases, the insurance will not cover before the new restoration.
Another problematic situation is when a filling was done but the tooth really should have been treated with a crown. Many insurance companies will not pay for the crown if a filling was done in the past five years.
Please note these are generalizations I have seen from working with different dental insurance companies. Please read your individual policy carefully for any limitation or exclusions on your specific plan
Many dental insurance plans can not be fully utilized when you first sign up for them. Preventive care might start on day one but a larger treatment option might have waiting periods.
We all like to find a deal but sometimes something is cheap for a reason. You might see some dental plans that only cover very specific or limited procedures like only preventative care. More complex procedures like fillings, crowns, or extractions may not be covered at all. I have seen patients with insurance plans that are almost impossible to save more on the insurance plan compared to paying out of pocket directly for treatment.
Insurance can be confusing for patients. That is why at We Care Dental Care, we work extremely hard to provide as much clear information about your insurance as possible for all of our patients.
Disclaimers
All the above suggestions are based on Dr. Burkitt’s experience with dealing with insurance companies. These suggestions should not be treated as legal advice. The above text is meant for education and entertainment purposes only. Each policy is different and should be evaluated individually to determine your coverage benefits and limitations.