Dental insurance works great to help prevent or maintain dental conditions, but dental insurance can be limited. Please understand your policy limitations and benefits. Our office always verifies dental coverage before the first visit. The more information provided to us, the better we can catch any issues with coverage. Dr. Talaie and Dr. Bina diagnosis conditions and recommend treatment based on clinical data, expertise, and visual exam. Although Dr. Talaie and Dr. Bina do not recommend treatment dictated by insurance limitations, our office does take each patient’s situation into account when discussing treatment options. There are ways to maximize coverage and get the most out of your dental plan. Dual coverage (spouse covers spouse), health savings accounts, care credit financing and supplemental plans like AFLAC dental, are some additional ways to help cover costs of treatment.
How dental insurance plans work
Employer-based dental PPO or Union benefits: dental plan pays dental office directly for services rendered. Patients pay a 0%-50% co-pay depending on service.
Our team knows that verifying benefits and having accurate benefit details is very important. Insurance companies have made the process more efficient via the web, but they also limit specific details, limits, and exclusions. Always try to receive as much information about your plan directly from your insurer.
Each patient gets a set yearly dollar maximum in coverage. Example: $1,000-$3,000 per year a dental plan will pay out on claims. Each year, the plan renews on a specific date but any amounts not used are lost and do not roll over. Some plans do have rollover or separate maximums for orthodontics or preventative procedures. Typical reset of benefits is January 1, but some plans renew at other times in the year such as June or September.
Deductibles usually range from $25-$100 per year and are applied to basic and restorative procedures. If you are stable and only go to the dentist twice per year, you will not likely pay a deductible. Deductibles are applied to the first treatment of the year, such as a filling, crown or deep cleaning. Dental insurance deducts the amount of deductible from the claim payment which is added to the patients total out of pocket. In some cases, there is no deductible, or it is applied to exams and x-rays.
Dental plans pay a percentage of a negotiated fee for a particular service. Offices that are in-network with a dental plan discount their private fee and only agree to charge the patient a set price for a procedure and any portion not covered by the plan.
Porcelain crown dentist fee $1,200
Porcelain crown insurance fee $800 (maximum we can charge patient)
Insurance pays 50% or $400
Patient pays 50% or $400
Here is a typical breakdown of percentages paid by dental PPO plans:
Preventative & diagnostic (exams, X-rays, regular cleaning) 100%
Basic (fillings, deep cleaning, extractions, root canal) 80%
Major (crowns, bridge, onlays, implant, dentures) 50%
*This is just an example, and your plan may be slightly different.
Frequency of coverage
Although most people are not familiar with details of their dental coverage, ‘two cleanings per year’ seems to be the number one benefit people know of and an example of the frequency of covered benefits. Dental plans allow for two cleanings anytime in a calendar year or two cleanings separated by six months. The six-month frequency applies to exams as well which is not helpful, but luckily we see less of this in plans. A dental plan will only pay towards a filling on a single tooth, every 24 months and every five years for a crown. Each plan has their frequency limits and rules, and some are not like others.
Orthodontic benefits are a separate lifetime maximum usually equal to the yearly maximum. Even though a patient seems to have orthodontic coverage included in a plan, an age limit may exclude the patient from benefits.
Spouses can be covered under each other’s dental plan if available. What one plan does not cover, the other will. Rules and details related to dual coverage are changing so make sure you ask your HR about coordination of benefits if you are interested in adding your spouse to your dental plan.
Open enrollment and switching to PPO
Open enrollment happens once or twice a year depending on the company and is the time to upgrade your dental plan, add a spouse or dependent and sign up for a health savings account. Health savings account (HSA) is when pre-tax dollars are set aside to help cover out of pocket medical or dental expenses. The patient just pays with a special visa/MC and provides their company with receipts. Not every company offers this benefit, but it is commonly used here at Century Smile. HMO plans seem only to benefit the insurance company, and most people come to realize that quickly. More and more providers are dropping HMO plans from their practice making it difficult for HMO patients to find a dentist. Quality of care is also a major problem as patients who have HMO are promised zero or very low out of pocket fees. HMO plans do not make up the difference, leaving the provider to cut corners, overbook the schedule, charge for extra services or simply do free dentistry. If you have dental plan options to choose from, always select a PPO option.
AFLAC offers dental plans to employers or individuals.
We accept AFLAC, and it is a great option if traditional dental insurance is not available. There are waiting periods to be met for certain procedures, but overall AFLAC has helped many patients in our practice get the treatment they needed.
Visit www.AFLAC.com/dental for more information
We take all PPO dental insurance. No insurance? We’ve got you covered. Inquire about individual coverage options such as Aflac, CareCredit® and even if you can’t afford to pay in full, we are willing to arrange an in-house payment plan.