Dental insurance can be incredibly confusing for patients to understand. Our office has been working with many types of insurance carriers for over 25 years and we have watched the industry undergo changes over these years. More recently, we have seen some very dramatic changes that have caused many patients to question why they are even paying for it in the first place. Let’s first review some of the basics, and then we can discuss in detail some of the things that frustrate patients.
When you become active on a plan you will be given a card or a group number. You will need this information to enable providers (dentist) to relay information to you regarding your benefits. However, you must realize that even though you have a card, a group number and have been paying premiums, many plans will invoke a waiting period on you. This sometimes means that before you can receive benefits for some types of services, you have to pay premiums for up to a year before your benefits kick in. These “types” of procedures are usually the ones that are more costly and/or immediately necessary, for example: root canals, crowns, or periodontal therapy.
…for some types of services, you have to pay premiums for up to a year before your benefits kick in. These “types” of procedures are usually the ones that are more costly and/or immediately necessary…
All dental procedures are classified according to one of about 10 categories. Your insurance pays benefits on these categories based on a percentage. Sometimes the percentage is 100% and sometimes 50%. For example, if your filling costs $300, your insurance may pay 50% of the fee they determine to be the maximum allowable. So if the insurance company’s max allowable fee is $200, they will pay 50% or $100 and you pay the rest ($200) as a co-payment. This is an example of traditional insurance. A common misunderstanding is, “if my insurance is supposed to pay 100%, why do I have to still pay some on a routine cleaning”? The reason is that the insurance company’s max allowable fee may be $85 for a cleaning, but your dentist’s fee may be $97. So the patient still ends up paying $12 on the procedure. Insurance companies will not disclose their maximum allowable fees. They keep this information proprietary and will not disclose it to the dentists. In this type of plan, the dentist has no connection or binding agreement to the insurance carrier. There can be yearly maximum limits, waiting periods on certain benefits, missing tooth clauses, yearly deductibles and co-payments.
Gone are the good old days of insurance benefits. Today, the consumer faces a much more complex array of factors: huge reductions in benefits, escalating plan costs and the necessity of having someone with inside knowledge to help you determine if your insurance company is actually giving you the correct level of benefits. All of these factors are used to decide if what you are buying is actually worthwhile.
Is the insurance you are paying for actually worthwhile?
Stay tuned for part two of “how insurance works”, as our next entry will discuss some of the new plans and how the industry is dramatically changing for our patients.
M. Scott Smith, DMD