Dental Insurance 101: What Everyone Should Know About Their Dental Insurance Plans
Dr. Harmeet Dhaliwal BSC, DDS
The most frequent concern dental offices deal with for patients doesn’t involve teeth. It’s what their dental insurance coverage is and what the patient will have to pay out of pocket. While we are health care providers trained to diagnose and plan treatment based on the dental health needs of each individual, the vast majority of patients opt to do treatment not based on their dental health needs but on what their dental insurance plan will allow for what they can afford to cover out-of-pocket.
We get it—dental care is not cheap, and everyone’s finances are tight these days. As such, most dental offices offer direct-billing or assignment, where the dental office bills the patient’s insurance company on their behalf and waits for the delta dental or blue cross blue shield insurance company to pay the dental office directly. In this scenario, patients usually only pay the remaining balance of what their insurance plan does not cover for treatment received.
The alternative is non-assignment, where a patient pays in full for their treatment at the dental office. Then they submit their receipts to their insurance company, which reimburses them directly. While non-assignment is a lot less work and stress for dental offices, most have chosen to offer direct billing because carrying costs can be too expensive for their patients.
When the coverage provided by their insurance company isn’t as high as the patient was expecting, leading to a higher out-of-pocket expense, they can become dissatisfied. To empower patients to take charge of their insurance coverage and avoid unpleasant payment surprises, the following is a list of tips and definitions to help you navigate the complex world of dental insurance.
Pre-determinations – Dental offices often send pre-determinations to a patient’s insurance company to determine the potential out-of-pocket expense for a patient after their insurance coverage, before any treatment is completed. This is only possible if patients diligently provide the dental office with their insurance information well in advance of their scheduled appointment. However, these are only estimates and not always completely accurate as a number of factors need to be taken into account. You should also ask if your insurance provider requires pre-determination for ALL treatment.
Yearly Maximum – What amount does your plan cover per year, and does it include basic treatment (cleanings, fillings, extractions) and major treatment (crowns, root canals) combined, or do those two have separate yearly maximums?
When does your insurance plan renew and the yearly maximum reset? Does it follow a calendar year or is it operating on a different 12-month interval?
What percentage does you plan cover? 100%? 80%? It is important to note that basic and major treatment will usually have different coverage percentages. When your plan covers 80%, that also means that you are responsible to pay the remaining 20% of the balance.
Does your insurance plan follow the Alberta Dental Fee Guide? People will understandably get upset as their plan says it covers 100% and yet there’s a remaining balance. This is most often due to the insurance plan setting a lower price to pay out for the procedure than the price listed in the Alberta Dental Fee Guide. So while it may be paying out at 100% of the cost it has set, it doesn’t cover the Alberta Dental Fee Guide price. The other time there can be a discrepancy is if the office has a slightly higher fee for a procedure due to either cost of higher quality materials or use of enhanced techniques.
Frequency – How many scaling units for cleanings are allowed in a 12-month period? How much polishing or fluoride in a 12-month period? What is the frequency for new patient exams, x-rays, check-ups? When it comes to new patient exams, for some patients it may be yearly, and for others it may be every three or five years. When patients change from one dental office to another, they must be aware that their choice will likely involve an initial out-of-pocket cost if they recently had a new patient exam at another clinic, depending on their insurance coverage.
Age restrictions – Some dental insurance plans have fluoride coverage for adults, while others only have it for kids under the age of 15. Age restrictions can also apply for orthodontic coverage (Invisalign treatment).
What type of dental insurance plan do you have? Does it cover basic, comprehensive basic, major, orthodontics? Are specialist fees included? Are lab fees (for appliances or crowns) covered?
- Assignment of benefits – Most insurance companies will pay the dental office; however, some may only reimburse the policy holder.
- Is there a waiting period on the plan? Many employers have a delay on their benefits plan which will affect new hires.
- Do you have more than 1 plan? Some people have a second coverage through a spouse, which can help to cover more costs.
- Did your plan recently change? If so, you need to inform your dental office as soon as possible as any previous pre-determinations done will no longer be accurate depending on the new plan’s details. This includes if you no longer have a primary insurance like Sigma, Delta Dental or Blue Cross Blue Shield and are only operating now on your secondary insurance, or vice versa.
If patients put in the work upfront to familiarise themselves with the above information about their insurance plan, they can work together with dental administrators to avoid those feared unknown costs. In recent years with enhanced privacy laws, it is also more difficult for administrators to get the full insurance picture for a patient to help out with these plan details. And while administrators work hard to often help patients, it’s ultimately the patient’s insurance plan and responsibility.
It’s highly recommended that patients either download the apps that many insurance companies offer nowadays that provide patients with their plan details in the palm of their hand, or note down the phone number to call your insurance company to obtain the plan details as they will release information to the patients before anyone else. Gathering this information and sharing it with your dental office well ahead of your appointment date will ensure a smooth and positive check out for everyone involved.