Understanding Your Dental Insurance
The best way to take full advantage of your dental coverage is to understand its features. Our best advise is to read your benefit information before your first appointment.
Most insurance companies offer a variety of benefit plans with different features. You may have co-workers or friends who are also covered by the same insurance carrier, but their coverage may differ from yours.
An in-network provider is one contracted with the dental insurance company to provide services to plan members for specific pre-negotiated rates.
An out-of-network provider is one not contracted with the dental insurance company. Although not contracted, the provider can still bill your insurance company.
Most dental plans have an annual dollar maximum. This is the maximum dollar amount a dental plan will pay toward the cost of dental care within a specific benefit period (usually January through December).
The patient is personally responsible for paying costs above the annual maximum. Consult your plan booklet for specific information about your plan.
Most dental plans have a specific dollar deductible. It works like your car insurance. During a benefit period, you personally will have to satisfy a portion of your dental bill before your benefit plan will contribute to your cost of dental treatment. Your plan information will describe how your deductible works. Plans do vary on this point. For instance, some dental plans will apply the deductible to diagnostic or preventative treatments, and others will not.
Classes or Categories of Coverage
Many dental plans offer three classes or categories of coverage. Each class provides specific types of treatment and typically covers those treatments at a certain percentage. Each class also specifies limitations and exclusions.
Class I procedures are diagnostic and preventative and typically are covered at the highest percentage. (Typically 80-100% of the plan's maximum allowance). This is to give patients a financial incentive to seek early or preventative care, such care can prevent more extensive treatment.
Class II includes basic procedures - such as fillings, extractions, and periodontal treatment. (Typically 60-80% of the plan's maximum allowance).
Class III is for major services (such as crowns, bridges, and implants) and is usually reimbursed at a lower percentage. (Typically 50% or lower of the plans maximum allowance).
If your dental care will be extensive, you may ask your dentist to complete and submit a request for a cost estimate, sometimes called a pre-treatment estimate. This will allow you to know in advance what procedures are covered, the amount the benefit plan is estimated to pay toward treatment or your estimated financial responsibility. A pre-treatment estimate is not a guarantee of payment. When the services are complete and a claim is received for payment, your insurance carrier will calculate payment based on your current eligibility, amount remaining in your annual maximum and any deductible requirements.
Limitations and Exclusions
Dental plans are designed to help with part of your dental expenses and may not always cover every dental need. The typical plan includes limitations and exclusions, meaning the plan does not cover every aspect of dental care. This can relate to the type or number of procedures, the number of visits or age limits. These limitations and exclusions are carefully detailed in your plan policy and warrant your attention.