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Thanks again Dr. Justin! I am so happy with how it turned out!
~Chris, Herkimer, NY
May 5, 2013 Insurance Introduction
April 15, 2013 I Dont Have Insurance
June 14, 2012 Why Your Dentist Costs So Much
May 28, 2012 “Should You Bite” Article
March 3, 2012 Alphabet Soup Of Insurance
February 6, 2012 Consumer’s Guide To Dental Insurance
January 20, 2012 Is Your Dentist Ripping You Off?
January 2, 2012 How Dental Fees Are Set
November 6, 2011 Selecting or Changing Your Dental Plan
October 6, 2011 How Do Dentists Feel
This definitely does not mean you should skip your appointments.
Preventative care is the best treatment to maintain dental health.
For example: Going to the dentist for the next TEN years 2x a year for regular maintenance appointments will cost you approximately 2500 dollars. If one filling is found early and fixed during that time it will cost 1/10th the price of major treatment on a tooth. Even with the best insurance major dental work is covered at 50% up the maximum dental plan limit that your policy may hold. You change the oil and tires to your car, please take the time to provide proper health care to your body.
If you still resist seeing the dentist, deciding to work though any pains and ignoring your dental health eventually the day will arise that you need to see the dentist. Despite the pain and problems any tooth may have, we may still be able to save it and eliminate your pain immediately. Extensive problems can be costly and complicated sometimes the tooth just needs to meet the tooth fairy.
Taking out a tooth that was once easily saved is more costly then fixing it in the beginning. Either way an investment went into your mouth. You are the one to decide when and what will be done.
All tooth drama can be easily prevented.
If you have not been to the dentist in a very long time you should schedule an appointment as soon as possible.
All tooth drama can be easily prevented.
Justin Zalatan D.D.S.
There’s no question that dental work is expensive – especially when you need to have major work done. If you’re not covered through your job, you may have to purchase it on your own. However, purchased privately, dental insurance can be a huge waste of money if your plan doesn’t match your needs. In this article we’ll show you how to drill through these plans to find out if dental insurance is right for you.
Overview of the System
First, here’s a breakdown of how private dental insurance works. You select a plan based on the providers (dentists) you want to be able to choose from and what you can afford to pay:
The monthly premiums will depend on the insurance company, your location and the plan you choose. For many people, the monthlypremium will be around $50 a month. This means that you’re spending $600 on dental costs each year even if you don’t get any work done.
Things to Consider
Now, you may be thinking that most people don’t come out ahead with most kinds of insurance, and you’d be right. After all, if insurance companies didn’t make a profit, they would all go out of business. Insurance is designed to protect you in a worst-case scenario. Dental insurance is significantly different from most other kinds of insurance, however. With policies like health insurance or homeowner’s insurance, the potential downside is so high that almost no one can afford the risk of not being insured. With dental insurance, the potential downside is fairly low – and so is the potential upside. (To learn more about these insurances, see Insurance Tips For Homeowners,Fighting The High Costs Of Healthcare and Five Insurance Policies Everyone Should Have.)
In a good year when you only need the standard cleanings, exams and x-rays, you are likely to lose about $200 by having dental insurance. While these services will generally be completely covered by your insurance because they are considered preventive care. If you paid out of pocket for them you would probably only spend around $400 for the year instead of the $600 you’re spending on insurance premiums.
Will It Be There When You Need It?
What about when you need some work done? In a really bad year, your dentist may inform you that you need a couple of fillings, a root canal and a crown. On top of that, you’ll still have to pay for your usual cleanings, exams and x-rays. This is the time to be insured, right? Unfortunately, your insurance may not be as helpful as you’d expect. Many dental insurance plans have very low annual maximums of around $1,000 (this will vary by plan and by provider, of course). This means that once your dental bills exceed $1,000 in any given year, you’re stuck paying the rest of the bills in full.
You may still pay a lower negotiated fee for the work you need as a benefit of having insurance, but even the negotiated fees are quite high. For example, if the dentist’s regular fee for a filling is $150, the negotiated fee might be $100. In this situation, your regular oral maintenance and fillings will use up most or all of your annual maximum, so only a fraction of your large dental work bill will actually be covered. You’re likely to still pay $1,000 to $2,000 out of pocket, plus your annual $600 in premiums. On top of that, while you may pay 0-10% in co-pays on preventive maintenance and 20% in co-pays on fillings, the co-pay on expensive procedures like root canals tends to be a whopping 50%. Even if you haven’t used up your annual maximum by the time you need the expensive procedure, you’ll still have to pay several hundred dollars for it.
Dental insurance also rarely covers expensive procedures like orthodontics and cosmetic dentistry, even if you try to argue that you need a procedure to alleviate emotional pain and suffering. When insurance does cover them, the annual maximums still often prevent you from saving very much, if anything, after you factor in your biannual cleanings and exams.
Waiting Could Be Worse
If you’re thinking that you’ll just hold out and then purchase dental insurance when you need it, think again. Because of what’s called a waiting or probationary period, this strategy won’t work (you didn’t really think you’d found a way to outsmart the insurance companies, did you?). Waiting periods mean that, for example, one year after you first become insured, your insurance will not cover any major work (like crowns or root canals) and for three months after you first become insured, they won’t pay for any minor work (like fillings). Insurance companies know that when you need a filling or a crown, you need it now – you won’t be able to find out you need a crown, buy insurance, wait 12 months, and then get it taken care of. If you tried to do that, you’d probably suffer from a lot of discomfort and ultimately lose your tooth (and you’d have to pay full price for that extraction, too).
Considerations for Group Plans
Surprisingly, even if your employer offers dental insurance, you might be better off skipping it. Many people assume that employer-sponsored benefits are automatically a good deal because you’re receiving a group rate, but this isn’t necessarily true. When evaluating your employer’s dental plan, make sure to really look at the monthly payments, the annual maximum and the co-payments. Your employer may offer you a great plan that’s only $20 a month to cover your entire family with a generous annual maximum, or a mediocre plan that’s $40 a month with a $1,000 annual maximum. With the former, you can really benefit, but with the latter, you’re probably wasting your money. Do the math for your own situation to determine whether you’re likely to come out ahead.
There is one situation where it can make sense to get dental insurance regardless of whether it seems like a good deal in the long run, and that is if you are someone who is currently living from paycheck to paycheck with little or no money in savings. When you don’t have dental insurance, you have to be able to pay a $1,600 bill when you have the work done (if not in full, then in prompt installments). If you can’t do it and your options are to overpay for dental insurance, neglect your only set of teeth or put dental work on a credit card that you’ll have trouble paying off, your best bet is to get the insurance. You’ll probably waste less money on insurance than you would paying interest on a credit card, not to mention that you wouldn’t want to ruin your credit score over a few fillings. (To read more about budgeting for your health costs, check out Health-y Savings Accounts and our Budgeting 101 feature.)
If you can’t participate in a quality group plan – either a preferred provider plan (PPO) or a Dental Health Maintenance Organization (DHMO) – the best way for most people to come out ahead on dental expenses is to pay for everything out of pocket. Brushing and flossing regularly, switching to an inexpensive electric toothbrush, getting professional cleanings every six months and going to a dentist who does high quality work that lasts for years can be the most effective ways to save money in the long run.
by Amy Fontinelle Amy Fontinelle is a financial journalist and editor for a variety of websites, public policy organizations, and book publishers. She has written hundreds of published articles and blog posts on topics including budgeting, credit management, real estate and investing. Her articles have been featured on the homepage of Yahoo! and on Yahoo! Finance, Forbes.com, SFGate.com and numerous local news websites.
Understanding the alphabet soup of dental insurance plans can be a difficult endeavor for most people. Two common insurance acronyms include PPO and HMO. Managed care plans are often either PPO or HMO, standing for preferred provider organization and health maintenance organization.
With PPO insurance plans, the companies negotiate fee schedules with dentists in exchange for the dentist being put on a list of “preferred” providers. Employers give the list to their employees to match them up with dentists who participate with the dental plan. Dental insurance can help people pay for dental treatment, but it has its limitations. Most insurance plans have a deductible of $50 to $100, pay only a specified percentage for each type of treatment, and have a yearly maximum amount of funds available for dental care.
Most PPO plans cover preventive care, cleanings, check-ups, protective dental sealants, x-rays, and fluoride treatment at 80-100%. Basic care, including root canal therapy, extractions, and fillings are usually covered at 80%. Major care such as crowns (caps), permanent bridgework, and full and partial dentures as well as periodontal (gum) care are often covered at 50%.
Many insurance companies have a yearly maximum of a $1000. Dental insurance is not cumulative, so if you don’t use it, you lose it. It is interesting, and disappointing, to note that when dental insurance companies became common in the early 1970′s, the yearly maximum in many was the same $1000 it is today, even though the cost of delivering dental care has nearly tripled since then.
HMO’s have received a barrage of negative publicity in recent years, primarily in the medical community, for dubious “gag” clauses in the contracts, bureaucratic snafus, and the limitation of appropriate care of patients by their physician. While some HMO insurance plans may be adequate for practitioners in the medical community, they are more difficult to justify in the dental community. The main reason is that practice overhead is generally higher in the average dental practice than the average medical practice, and the financial compensation from most HMO’s is very low. 65 to 70 cents of every dollar received at the average dental office is consumed by office overhead, including staff salaries, supplies, laboratory fees, rent, etc.
The reduced fees allowed by dental HMO’s has participating dentists doing many dental treatments at a financial loss. A recent study by the American Dental Association found that the average dental HMO does not even adequately reimburse inexpensive preventive dental care. Consequently, a dental practice with a majority of patients having HMO insurance is often forced to see patients quickly- too quickly in my opinion, to develop the necessary rapport essential to the dentist- patient relationship. A dentist I know told me that when an HMO patient comes into his office for a cleaning, he does not give that patient the “free” toothbrush that he routinely gives to his other patients.
As you might have guessed, I am not a big fan of HMO’s. We do not participate with any HMO’s but are involved with some PPO’s. Dental insurance can help people pay for routine dental visits, but it has many limitations. Always discuss your insurance plan and financial obligations with either your dentist or the office manager prior to dental treatment.
by Dr. Jerry Gordon © 1998-2011 HowStuffWorks, IncReserved.
When most people think about health insurance, they think first about covering costs of treatment for serious medical conditions or accidents. That’s a natural thing to do. But there’s another type of insurance that’s equally important to your well being–dental insurance. Because dental disease is so common, being protected by dental insurance and using it wisely are essential safeguards for you and your family.
Unlike medical disease, which can be both unpredictable and catastrophic, most dental ailments are preventable. Preventive care, including regular checkups and cleanings, is the key to maintaining your oral health. With regular visits to the dentist, problems can be diagnosed early and treated without extensive testing or elaborate and expensive procedures. That keeps the costs of dental care much lower than those of medical care. In fact, total spending for dental care is decreasing. In 1970, it made up 6.3 percent of total health care expenditures. But in 1991, dental care’s share of health care spending was only 4.9 percent.
Medical insurance is designed primarily to cover the costs of diagnosing, treating and curing serious illnesses. This process may involve a primary care physician and multiple specialists, a variety of tests performed by doctors and laboratories, multiple procedures and masses of medications. Depending on the health, age and attitudes of people in the medical coverage group, costs can fluctuate widely.
Dental insurance works differently. Most dental coverage is designed to ensure that the patient receives regular preventive care. High quality dental care rarely requires the complex, multiple resources often required by medical care. A thorough examination by the dentist and a set of x-rays are all it usually takes to diagnose a problem. By and large, dental care is provided by a general practitioner, although some cases may require the services of a dental specialist. Because most dental disease is preventable, dental benefits plans are structured to encourage patients to get the regular, routine care so vital to preventing and diagnosing the onset of serious disease.
In fact, most dental benefits plans require patients to assume a greater portion of the costs for treatment of dental disease than for preventive procedures. By placing an emphasis on prevention, and by covering regular teeth cleaning and check-ups, Americans saved nearly $100 billion in dental care costs during the 1980s.
The availability of dental insurance is the single greatest factor in helping you get the dental care you need. More than 48 percent of all Americans–113 million of us–are covered by privately financed dental insurance plans. This compares with just 12 million people who had such coverage in 1970. As a result of increased access to regular care and the widespread use of preventive measures, the incidence of dental decay has dropped sharply. Half of today’s school children never have had a cavity.
Consumers can choose from an assortment of dental benefits plans that accommodate a variety of needs and expectations. The following factors differentiate one plan from another:
1. the type of third party responsible for funding and administration of the plan;
2. the alternatives offered for selecting a dentist;
3. the structure used to compensate the dentist for services provided; and
4. the method by which benefits and payments are calculated.
Understanding these differences is essential to making an informed decision when selecting a plan and using the benefits.
Regardless of the dental benefits plan, there are usually three parties involved: you, the patient; the dentist providing care; and a third party with whom you or your employer contracts for coverage. If your options include a plan funded by your employer, you may have an administrator responsible for processing and payment of claims. The primary responsibility of the third party is to provide the financial foundation for your dental benefits plan. There are three types of third parties.
Dental Service Corporations. These not-for-profit organizations negotiate and administer contracts for dental care to individuals or specific groups of patients. Delta Dental Plan and Blue Cross/Blue Shield Plans are examples of this third party type.
Insurance Carriers. These for-profit companies underwrite the financial risk of, and process payment claims for, dental services. Carriers contract with individuals or patient groups to offer a variety of dental benefits packages, often including both fee-for-service and managed care plans.
Self-Funded Insurers. These companies use their own funds to underwrite the expense of providing dental care to their employees. The company pays for the dental costs of its employees, usually with limitations on services and fixed-dollar allocations.
Dental benefits plans can be categorized by the options offered for selecting a dentist. Some plans allow you the freedom to choose your own dentist, while others, in exchange for lower rates, limit your choice. These two alternatives are called open and closed panel plans.
Open Panel. This type of dental benefits plan allows covered patients to receive care from any dentist and allows any dentist to participate. Any dentist may accept or refuse to treat patients enrolled in the plan. Open panel plans often are described as freedom of choice plans.
Closed Panel. This type of plan allows covered patients to receive care only from dentists who have signed a contract of participation with the third party. The third party contracts with a certain percentage of dentists within a particular geographic area. There are two types of closed panel plans.
Preferred Provider Organization (PPO) - This plan allows a particular group of patients to receive dental care from a defined panel of dentists. The participating dentist agrees to charge less than usual fees to this specific patient base, providing savings for the plan purchaser. If the patient chooses to see a dentist who is not designated as a “preferred provider,” that patient may be required to pay a greater share of the fee-for-service.
Exclusive Provider Organization (EPO) - This closed panel plan allows a particular group of patients to receive dental care only from participating dentists. Although there may be some exceptions for emergency and out-of-area care, if a patient decides to see a dentist which is not listed on the EPO panel, charges for service will not be covered by the plan. Because participating dentists are required to offer substantial fee reductions, many dentists elect not to participate in EPO-type plans. Under some benefits plans, participating dentists may be salaried employees of the EPO. An EPO contracts with a limited number of practitioners within a geographic area. Access to necessary specialized care can be restricted. The EPO also may limit the amount of services that a patient can receive in a given calendar year.
When choosing a benefits plan, it is important to know who pays what to whom. Dental plans can be categorized into three types based on the compensation and treatment provided.
Indemnity Plans. This type of plan pays the dentist on a traditional fee-for-service basis. A monthly premium is paid by the patient and/or the employer to an insurance carrier, which directly reimburses the dentist for the services provided. Insurance companies usually pay between 50 percent and 80 percent of the dentist’s fee for covered services; the remaining 20 percent to 50 percent is paid by the patient. These plans often have a pre-determined deductible, a dollar amount which varies from plan to plan, that the patient must pay before the insurance carrier will begin paying for care. Indemnity plans also can limit the amount of services covered within a given year and pay the dentist based on a variety of fee schedules.
Capitation Plans. This type of plan provides comprehensive dental care to enrolled patients through designated provider dentists. A Dental Health Maintenance Organization (DHMO) is a common example of a capitation plan. The dentist is paid on a per capita (per head) basis rather than for actual treatment provided. Participating dentists receive a fixed monthly fee based on the number of patients assigned to the office. In addition to premiums, patient co-payments may be required for each visit.
Direct Reimbursement Plans. Under this self-funded plan, an employer or company sponsor pays for dental care with its own funds, rather than paying premiums to an insurance carrier or third party. The patient pays the dentist directly and, once furnished with a receipt showing payment and services received, the employer reimburses the employee a fixed percentage of the dental care costs. The plan may limit the amount of dollars an employee can spend on dental care within a given year, but often places no limit on services provided. Patients can select a dentist of their choice and, in conjunction with the dentists, can play an active role in planning the treatment most appropriate and affordable to ensure optimum oral health.
A clear understanding of the methods used to calculate benefits and payments will allow you to compare and evaluate the purchasing power of different plans. The following are four common payment schedules.
Capitation (per capita). This fee schedule is used by plans structured to provide a predefined level of benefits. Because dental care needs vary by individual, it is critical to have a thorough understanding of the level or range of services “defined” or covered by the plan. Under this fee schedule, the patient is responsible to pay for treatment not covered within the scope of the plan. In some cases, the allocated payment a dentist receives from the benefits plan, including patient co-payments, is less than the actual cost of providing care. Patients often settle for less-than-optimal treatment alternatives or postpone necessary services when their co-payments do not cover all possible options.
Table of Schedule of Allowances. Plans using this form of benefits calculation establish a maximum dollar limit for each covered procedure, regardless of the fee charged by the dentist. If you select a plan that uses this type of table or schedule, ask how often the table is adjusted for inflation or for changes in accepted dental procedures. In these plans, the difference between the allowed charge and the dentist’s fee is paid directly by the patient.
Patients should understand that contracted fee reductions listed in some plan allowance schedules can significantly diminish the level and quality of care delivered. Contracted rates are based on the size of the patient population and projections of the amount and type of treatment performed within a given time frame. Since cost control drives this payment approach, your ability to choose your dentist or see a specialist may be limited.
Direct Reimbursement. In this self-funded plan, the patient pays the doctor for services. The employer or plan sponsor reimburses the employee for a predetermined percentage of all costs. Under this fee schedule, the employee has an incentive to work with the dentist to plan healthy and economical solutions.
Usual, Customary & Reasonable (UCR). Most indemnity (traditional fee-for-service) plans use this payment schedule. It allows patients to select their own dentist. The UCR schedule pays benefits based on a fixed percentage of the lesser of the dentist’s fee or the fee determined by the insurance carrier to be “usual,” “customary” or “reasonable” for the service in the community in which the service was delivered. Wide fluctuations in UCR fees between communities have made this payment system highly controversial. Because many insurance carriers set the UCR percentage too low in comparison to the area’s usual professional fees, patients may wind up paying more out-of-pocket. Most payments are made directly to the dentist, but in some instances they are made to the beneficiary.
Today’s health insurance, including your dental plan, is designed to help you get the care you need at a reasonable cost. Because each person’s oral health is different, costs can vary widely. To control dental treatment costs, most plans will limit the amount of care you can receive in a given year. This is done by placing a dollar “cap” or limit on the amount of benefits you can receive, or by restricting the number or type of services that are covered. Some plans may totally exclude certain services or treatment to lower costs. Know specifically what services your plan covers and excludes.
There are, however, certain limitations and exclusions in most dental benefits plans that are designed to keep dentistry’s costs from going up without penalizing the patient. All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes dental coverage and health insurance may overlap. Read and understand the conditions of your dental plan. Exclusions in your dental plan may be covered by your medical insurance.
The California Dental Association encourages consumers to choose plans that impose dollar or service limitations, rather than those that exclude categories of service. By doing so, you can receive the care that’s best for you and actively participate with the dentist in the development of treatment plans that give the most and highest quality care.
To help you stretch each dental benefit dollar, most plans provide patients and purchasers with special administrative services. Find out if your plan provides the following mechanisms to help you budget, analyze and dispute, if necessary, the costs of your dental care.
Predetermination of Costs. Some plans encourage you or your dentist to submit a treatment proposal to the plan administrator before receiving treatment. After review, the plan administrator may determine: the patient’s eligibility; the eligibility period; services covered; the patient’s required co-payment; and the maximum limitation. Some plans require predetermination for treatment exceeding a specified dollar amount. This process is also known as preauthorization, precertification, pretreatment review or prior authorization.
Although your dental benefits plan may not be bound to predetermined costs, this mechanism can help you and your dentist plan and budget a treatment plan appropriate to your oral health needs.
Annual Benefits Limitations. To help contain costs, your plan may limit your benefits by number of procedures and/or dollar amount in a given year. In most cases, particularly if you’ve been getting regular preventive care, these limitations allow for adequate coverage. By knowing in advance what and how much your plan allows, you and your dentist can plan treatment that will minimize your out-of-pocket expenses while maximizing compensation offered by your benefits plan.
Peer Review for Dispute Resolution. Many plans provide a peer review mechanism through which disputes between third parties, patients and dentists can be resolved, eliminating many costly court cases. Peer review is established to ensure fairness, individual case consideration and a thorough examination of records, treatment procedures and results. Most disputes can be resolved satisfactorily for all parties.
Premium Adjustments and Reevaluations. Patients and plan purchasers should insist on regular reviews of premium levels to ensure that UCR or Table of Allowances payment schedules are equitable. This analysis can help optimize your benefit levels, ensuring that every dollar you spend is used wisely.
Coordination of Benefits. If you are covered under two dental benefits plans, notify the administrator or carrier of your primary plan about your dual coverage status. Plan benefits coordination can help protect your rights and maximize your entitled benefits. In some cases you may be assured full coverage where plan benefits overlap, and receive a benefit from one plan where the other plan lists an exclusion.
What looks like a bargain today may not be a good buy in the long run. While your out-of-pocket costs are, of course, an important part of your decision-making process when choosing a dental plan, they are not the only criteria to use when evaluating your options. Your primary focus should be to determine whether the coverage will satisfy your dental care needs. Consider the following:
1. Does the plan give you the freedom to choose your own dentist or are you restricted to a panel of dentists selected by the insurance company? If you have a family dentist with whom you are satisfied, consider the effects changing dentists will have on the quality or quantity of care you receive. Because regular visits to the dentist reduce the likelihood of developing serious dental disease, it’s best to have and maintain an established relationship with a dentist you trust.
2. Who controls treatment decisions–you and your dentist or the dental plan? Many plans require dentists to follow treatment plans that rely on a Least Expensive Alternative Treatment (LEAT) approach. If there are multiple treatment options for a specific condition, the plan will pay for the less expensive treatment option. If you choose a treatment option that may better suit your individual needs and your long-term oral health, you will be responsible for paying the difference in costs. It’s important to know who makes the treatment decisions under your plan. These cost control measures may have an impact on the quality of care you’ll receive.
3. Does the plan cover diagnostic, preventive and emergency services? If so, to what extent? Most dental plans provide coverage for selected diagnostic services, preventive care and emergency treatment that are basic for maintaining good oral health. But the extent or frequency of the services covered by some plans may be limited. Depending upon your individual oral health needs, you may be required to pay the dentist directly for a portion of this basic care. Find out how much treatment is allowed in any given year without cost to you, and how much you will have to pay for yourself.
Every dental care plan is different. It’s your responsibility to be informed about what your specific plan will cover. As a basis of comparison, the following services should be covered in full, with no deductible or patient co-payment:
Initial Oral Examination–once per dentist
Recall Examinations–twice per year
Complete x-ray survey–once every three years
Cavity-detecting bite-wing x-rays–once per year
Prophylaxis or teeth cleaning–twice per year
Topical Fluoride treatment–twice per year
Sealants–for those under age 18
4. What routine corrective treatment is covered by the dental plan? What share of the costs will be yours? While preventive care lessens the risk of serious dental disease, additional treatment may be required to ensure optimal health. A broad range of treatment can be defined as routine. Most plans cover 70 percent to 80 percent of such treatment. Patients are responsible for the remaining costs. Examples of routine care include:
Restorative care - amalgam and composite resin fillings and stainless steel crowns on primary teeth
Endodontics - treatment of root canals and removal of tooth nerves
Oral Surgery - tooth removal (not including bony impaction) and minor surgical procedures such as tissue biopsy and drainage of minor oral infections.
Periodontics - treatment of uncomplicated periodontal disease including scaling, root planning and management of acute infections or lesions
Prosthodontics–repair and/or relining or reseating of existing dentures and bridges.
Understand what routine dental care is covered by the plan, and what percentage of the costs will come our of your pocket.
5. What major dental care is covered by the plan? What percentage of these costs will you be required to pay? Since dental benefits encourage you to get preventive care, which often eliminates the need for major dental work, most plans are not generous when it comes to paying for major dental work, most plans cover less than 50 percent of the cost of major treatment. Most plans limit the benefits–both in number of procedures and dollar amount–that are covered in a given year. Be aware of these restrictions when choosing your plan and as you and your dentist develop treatment best suited for you. Major dental care includes:
Restorative care–gold restorations and individual crowns
Oral Surgery–removal of impacted teeth and complex oral surgery procedures.
Periodontics–treatment of complicated periodontal disease requiring surgery involving bones, underlying tissues or bone grafts.
Orthodontics–treatment including retainers, braces and/or diagnostic materials.
Dental Implants–either surgical placement or restoration
Prosthodontics–fixed bridges, partial dentures and removable or fixed dentures.
6. Will the plan allow referrals to specialists? Will my dentist and I be able to choose the specialist? Some plans limit referrals to specialists. Your dentist may be required to refer you to a limited selection of specialists who have contracted with the plan’s third party. You also may be required to get permission from the plan administrator before being referred to a specialist. If you choose a plan with these limitations, make sure qualified specialists are available in your area. Look for a plan with a broad selection of different types of specialists. If you have children, you may prefer a plan that allows a pediatric dentist to be your child’s primary care dentist. Since specialized treatment is generally more costly than routine care, some plans discourage the use of specialists. While many general practitioners are qualified to perform some specialized services, complex procedures often require the skills of a dentist with special training. Discuss the options with your dentist before deciding who is best qualified to deliver treatment.
7. Can you see the dentist when you need to, and schedule appointment times convenient for you? Dentists participating in closed panel or capitation plans may have select hours to see plan patients. They may schedule appointments for these patients on given days, or at specified hours of the day, restricting your access. Some dentist’s fees for seeing you on weekends or during emergencies are high than those the plan allows. You may be required to pay additional costs yourself. If you select these types of plans, have a clear understanding of your dentist’s policies as well as the plan’s dentist-to-patient ratio. It’s the best way to ensure your access to care is not unduly restricted and that you are not surprised by higher fees the plan does not cover.
8. Will the plan provide benefits to patients who may also be covered by another dental plan? It is not unusual to be eligible for dual benefits. You may be covered under your company’s plan as well as under that of your spouse’s employer. In analyzing your options, make sure to look for a plan that allows coordination of benefits.
You should be entitled to either 100 percent coverage or some form of premium credit. By coordinating benefits, you can eliminate being penalized or denied coverage when the two plans have conflicting exclusions.
To take full advantage of your dental benefits plan, visit the dentist regularly and get the preventive care that will keep your mouth healthy. Follow the treatment plan you and your dentist have developed. Do your dental homework–brush and floss regularly and maintain a regular schedule of oral examinations and teeth cleanings.
Should you need treatment for particular conditions, follow the procedure for predetermination required by your plan. Find out what your insurance will cover. Feel free to discuss a payment plan with your dentist for your portion of the treatment costs.
The law mandates that consumers with dental coverage receive a fully detailed patient information handbook–a Description of Benefits–that clearly outlines coverage, limitations and exclusions. Before selecting a plan that best suits your needs, ask your carrier or company benefits coordinator for a copy of the benefits handbook. If you have questions about coverage, exclusions, calculation of benefits or payment of benefits, ask before making your plan selection. Find out which plans your dentist participates in and why. That’s the best way for you to get care from the dentist of your choice, and still take advantage of the costs savings due to you.
Selecting an insurance program wisely isn’t simple. But having the facts to make an informed decision can make a difference. No plan is perfect; each has its advantages and limitations. Read the fine print. And by all means ask questions. The more you know about dental benefits, the better equipped you will be to select the best coverage for your dental health.
The California Dental Association (CDA) presents this information in the public interest. The information provided should not be construed as either an endorsement or recommendation by CDA. While this brochure attempts to be comprehensive, there may be questions that it has not answered fully. Consult your insurance carrier, insurance broker or company benefits coordinator for complete information.
CALIFORNIA DENTAL ASSOCIATION We Like To See You Smile
P.O. Box 13749, Sacramento, CA 95853-4749 © 1995 CDA
A person near and dear to me came home from the dentist with an ugly diagnosis. He has two cracked crowns and needs replacements. I’m not sure what’s more painful — what’s been going on in his mouth or the bite out of the family finances.
Cost of the crowns: $1,395 apiece. Cost of foundation fillings, or “cores” to put the crowns on: $326 apiece. Total bill, if you’re scoring at home: $3,442.
His dentist sold him membership into an office savings plan for $319 for the year. So that saves him 20% on all dental procedures and gives him two free cleanings. Knock off 20% (but add back in the $319) and we’re down to $3072.60 on this bit of drilling.
When I look at this bill, I wonder why I obsess about the weekly price fluctuations of Cheerios or the shrinking size of a can of tuna. All the economical choices a family makes in a year can be wiped out by a trip to the dentist. No wonder people are going to Thailand and Mexico for dental work.
Out of curiosity I called two other dentists within five miles of the first guy. One charges $950 for a crown. Another charges $797. According to 2009 figures from the American Dental Association, the national average among a survey of 8,085 dentists was $945.27. So how can the first guy explain why his price is $450 higher? The office assistant told me “not all dentists are created equal,” and of course, this dentist is one of the best in the area, using a great lab.
I’m not satisfied with that answer. The patient, however, trusts this dentist, and only this dentist, to drill in his mouth, and I’m not going to argue. But how can someone who is not a medical professional know if their dentist is worth their fees? I spoke to Dr. Matthew Messina, D.D.S., a dentist in Fairview Park, Ohio, and a spokesman for the ADA, about this question. (His price of a crown is usually in the high $900 range.) Here’s what I learned:
It’s fair to comparison shop. If your dentist is more expensive than everyone else in the area, “ask the dentist to explain the differences in their fees. That’s a perfectly reasonable thing to do,” Messina says. “It might be different laboratories, it might be different materials in the crown. It’s worth asking the question.”
But don’t select a dentist on price alone. “With crowns, we’re talking replacement body parts, if you will,” Messina says. “There’s a tremendous emotional component to it — besides having someone in your personal space. It’s important to see someone you trust.”
Rely on word of mouth. Get referrals from friends and neighbors. Fees are one part of evaluating a dental practice, but you want to have confidence in the office, the people in there, how they sterilize their instruments, and the training and continuing education of the dentist. Does he or she seem to be looking out for your best interests over the long haul? What’s the dentist’s philosophy for keeping your teeth healthy for a lifetime?
Prevention saves a boatload of money. Brush, floss, and use your fluoride rinse. Messina’s top three no-no foods for patients: Sour Patch Kids, popcorn, and chewing ice. “Ice is a crystal. Tooth enamel is a crystal,” he says. “When you push two crystals together, one of them breaks. Most of the times it’s the ice. Sometimes it’s the tooth.”
Interrogate. Why do I need this? Why is this investment important for me in the long run? What do you project my ongoing needs to be? Ask these questions. When you understand the value, you might not cringe at the cost so much.
Is the work guaranteed? Messina says five to seven years is typical for a crown. Will your dentist stand behind his or her work for that time?
Is your dental insurance worth it? Do the math. Sometimes, what the patient gets back in benefits is less than what they pay in premiums. “There are situations where we’ll talk to people about that,” Messina says. “Based upon their past history and projected future needs, they may be better off using a health savings account.”
By Sarah Lorge Butler © 2011 CBS Interactive Inc.. All Rights Reserved.
If you’re like most people, you probably don’t pay that much attention to your dental benefit plan. You know you’ve got one, but somehow reading that big book that outlines the details has never made it to the top of your list. Ever wonder what it says?
In a nutshell, it tells you that your employer has contracted with an insurance company to pay for a predetermined portion of your dental care. It also outlines what dental services your employer has agreed to pay for and which dentists you can see.
It’s important for you to read and understand your benefit plan. Keep in mind, though, that your insurance plan might not adequately provide for all of your dental treatment options. Only you and your dentist can decide what treatment best meets your dental needs, so don’t rule out a procedure if your insurance won’t cover it.
How are my dentist’s fees determined?
Your dentist charges you a fee for the actual treatment performed and the time it took to complete, as well as a portion of the office overhead. Your dentist’s overhead includes the cost of having quality staff, state-of-the-art equipment, modern dental materials, current infection control procedures, and continuing education to ensure that your dental team is up-to-date on the latest techniques.
How are my dental benefits determined?
Your benefits depend on the contract your employer has set up with the insurance company. Your employer pays the insurance company a specific premium, which the insurance company in turn uses to pay for your care. The higher the premium your employer pays, the less you will be expected to pay out of your own pocket.
When you’re looking at the description of your dental plan, check carefully to see which services will be fully covered by your insurance and which ones will require you to “co-pay,” or shell out your own cash for some or all of the services.
Most insurance plans use a “usual, customary and reasonable” (UCR) fee schedule to decide what portion of the dental treatment it will pay for.
A UCR plan will pay either a set percentage of the dentist’s fees, or its “reasonable” or “customary” fee limit – whichever is less. Because these limits are set by your employer’s contract with the insurance company, they may or may not reflect the actual costs of dental care in your area. If a plan’s “customary” fee limits are unrealistically low, you will end up paying a larger portion of the treatment costs.
Again, the amount of reimbursement depends on the specific dental plan that has been purchased. The insurance company can set limits on the amount paid for any dental procedure. For example, if the plan pays at the 80 percent level, that means 80 percent of the UCR fee as determined by the insurance company, not the actual fee charged by the dentist.
Why is there such a big difference between the amount insurance companies will pay?
There are no standards for determining UCR fees. Even if two insurance plans are housed in the same building and owned by the same company, the plans’ administrators might come up with different UCR rates for the same procedure.
For illustration’s sake, lets say 40 people from your town went to see their dentists on the same day to have a missing tooth replaced and those dentists all charge the same price for the procedure. When the bill arrives, each patient is charged an amount that varies by as much as 136 percent.
That’s UCR rates at work. What you pay depends entirely on your employer’s benefit contract and your plan administrator’s UCR fee structure.
What should I do if I get a letter from my insurance company?
If you get a letter from your insurance company stating that your dentist’s fees are above its UCR rate, talk to your dentist. Your insurance company might have out-of-date information, or might not have considered local factors when it set its fee schedule.
If after talking to your dentist and your insurance company you are still not satisfied, talk to your employer or union to let them know that the mask your dental benefit plan is hiding behind didn’t fool you for a second.
Copyright © 2011 Michigan Dental Association.
Before selecting or changing a dental plan, there are some important things to consider. Some plans require patients to choose a dentist from a limited list of dentists. Choosing from a list is not the same thing as freedom of choice. If your dentist is not on such a list, don’t hesitate to ask why he or she has elected not to participate.
Dental plans are typically business arrangements between an insurance company and an employer. Most plans are designed to pay only a portion of your dental expenses. However, dental plans may exclude or discourage certain treatments, such as dental sealants, which can prevent tooth decay and save you money later on. Carefully read a plan and know its limitations. If a plan doesn’t cover a procedure that is recommended by your dentist, this does not mean that the treatment isn’t appropriate or needed.
Some plans do not cover pre-existing conditions, such as missing teeth. Others may not cover dental implants, specialist referrals and other dental needs. Even when you and your dentist agree on the appropriate treatment method for your condition, the contract provision of the dental plan may only pay a portion, or pay only for the least expensive alternative treatment (LEAT) as determined by the insurance company.
Dental plans may use the terms “usual, customary and reasonable” (UCR) to determine the portion of the dental treatment fee they will pay. UCR reimbursement levels are determined by different methods by the dental plan administrators. They may vary a great deal among plans – even when those plans operate in the same area. The fee the insurance company determines to be “customary” may be very low compared to the area’s average professional fee for the same services. The plans then generally pay a certain percentage of the UCR level. The patient may then be required to pay a greater portion of the treatment costs.
Ask yourself the following questions before selecting a new plan:
You and your dentist make the decision about treatment. While dental benefit coverage should be taken into consideration, it should not be the deciding factor in determining your choice of treatment.
There are numerous models of dental plans. In general, they can be divided into two categories: managed care and fee-for-service. Managed Care dental plans are cost containment systems that direct the utilization of health care by a) restricting the type, level and frequency of treatment; b) limiting the access to care; and c) controlling the level of reimbursement for services. Fee-for-Service dental plans are typically freedom-of-choice arrangements under which a dentist is paid for each service rendered according to the fees established by the dentist.
Preferred Provider Organization
Preferred Provider Organization (PPO) programs are plans under which patients select a dentist from a network or list of providers who have agreed, by contract, to discount their fees. In PPOs that allow patients to receive treatment from a non-participating dentist, patients will be penalized with higher deductibles and co-payments. PPOs can be fully insured or self-insured. PPOs are usually less expensive than comparable indemnity plans and are regulated under the appropriate insurance statutes in the company’s state of domicile and operation.
Dental Health Maintenance Organization/Capitation Plan
Dental Health Maintenance Organization (DHMO) or capitation plans pay contracted dentists a fixed amount (usually on a monthly basis) per enrolled family or individual, regardless of utilization. In return, the dentists agree to provide specific types of treatment to the patient at no charge (for other treatments, a co-payment is required). Theoretically, the DHMO rewards dentists who keep patients in good health, thereby keeping costs low. DHMO models typically offer the least expensive dental plans.
If the plan purchaser is reviewing a DHMO or capitation plan, the following factors should be considered:
Direct Reimbursement (DR) is a self-funded dental benefits plan that reimburses patients according to dollars spent on dental care, not type of treatment received. It allows the patient complete freedom to choose any dentist. Instead of paying monthly insurance premiums, even for employees who don’t use the dentist, employers pay a percentage of actual treatments received. Moreover, employers are removed from the potential responsibility of influencing treatment decisions due to plan selection or sponsorship. DR is the ADA’s preferred method of financing dental treatment.
Patients often are surprised to find that their insurance benefits do not cover all the treatment their dentist recommends. Dental insurance benefits for the most part have remained at the same level for more than two decades, leaving patients to pick up any added costs out-of-pocket. In recent years, payment options have emerged to help patients bridge the gap between what their insurance covers and the total cost of care. Most dental practice will accept cash, personal checks or major credit cared, but many also offer outside monthly financing programs. These payment plans have rapidly gained popularity.
© 1995-2011 American Dental Association.
When we asked dentists if they would like to see their colleagues organize against dental insurance companies, the answer was a resounding “Yes!” from fully 94% of respondents.
especially given that most payouts haven’t risen in decades. “Insurance benefits no one but the insurance company,” wrote one dentist. “Their mantra is ‘Ignore, Compartmentalize, and Deny!’” wrote another.
Note: Survey sample included 171 respondents. Copyright ©2011 Du Molin & Du Molin, Inc. All rights reserved