As dental professionals, we get asked all the time “what is the best insurance?” or a variation of “Why is dental coverage so lousy?”.
And our patients have a point. Dental insurance typically is pretty lousy, for the patient and the dentist. There’s not enough coverage, too many things aren’t covered at all, the co-pays are too high, and the limitations are fairly strict. But why is this so?
And the reason is a fairly simple one, dental insurance is simply not profitable to insurance companies. Now, why isn’t it profitable … well, there are lots of reasons and speculation for that. I wish I could say “well, it’s because of XYZ, and if that gets fixed, it’s all sunshine and rainbows” (or fillings and root canals if you prefer). But that’s just not so.
But when you change your perspective about dental coverage, you will begin to understand that dental care should not be limited to accommodate what insurance companies will cover. For instance, many dental policies have very strict guideliness that (unfortunately) determine the treatment plan for the patient. These guideliness are a broad “one size fits all” approach to dental care, which really hinders the treatment that a dentist can offer on a case per case basis. If your dentist is only giving you the options that your insurance will cover, chances are you are not getting the whole story about what treatment might be better.
For example, some policies that do not cover endodontic treatment for certain teeth would instead cover an extraction.
The best way to take full advantage of your insurance coverage is by understanding how it works. It may seem daunting at first and each insurance plan is designed differently, however there are some basics that can help you get a better idea of how you’re covered.
If you have the benefit of dental insurance provided by your employer, consider yourself lucky. Think of this benefit as a valuable “coupon” that can greatly reduce the cost of dental care. Almost all dental plans are the result of a contract between your employer and an insurance company. Your dental coverage is not based on what you need or what your dentist recommends. Employers generally choose to cover some, but not all, of employees’ dental costs.
For the most part, insurance coverage is broken down into three or four categories: preventive care, basic, major and orthodontic.
Preventive care is usually covered by the insurance by 100%. Routine cleanings, exams dental xrays, flouride treatment and children’s sealants are usually covered as preventive. However, most insurances limit the frequency of each of these services. Some patients may require to upkeep with more frequent dental cleanings due to active orthodontic treatment or periodontal issues, but insurances will limit the number of times a cleaning can be performed.
Basic care is usually covered at a percentage, leaving the patient with copayments to cover the portions that the insurance will not pay. Additionally, most policies have a yearly deductible that applies for basic work. This deductible can vary for each plan. Usual services under basic care are fillings, deep cleanings, root canals, and some simple extractions among other services.
Major work usually requires a pre approval from the insurance company. If the proposed treatment is approved, the insurance will notify the patient what percentage is their financial responsibility. Most major work consists of prosthetics such as crowns, bridges, partial and complete dentures and occasionally some oral surgery or surgical extractions.
Additionally, some policies may cover braces. Orthodontic treatment is also covered at a percentage of the fees and it needs to be pre approved by the dental insurance. The guideliness they follow to determine eligibility for this service, may not always benefit the patient.
To provide “full coverage,” an insurance company would have to charge more for premiums than a consumer would deem worth spending. So we get this hybrid “this is covered up to that amount/waiting periods/low maximums/no coverage at all” scenario that we’re in. Which really helps nobody — insurance companies don’t like it, as dental profesionals, we don’t like it and patients don’t like it.
There are no easy answers. But at least now you sort of have an inkling as to how dental insurance works.
What do you think about this subject?
Until next time, keep smiling.
by: Paola H