Do I need dental insurance?
Well, not really. You don't need dental insurance to go to the dentist. Many dentists will accept credit cards, cash, checks, or other forms of payment. It does not have to be dental insurance. However, if you have dental insurance and you would like to know how it works, there you go.
What are the types of dental insurance?
Number one, there's a difference in the type of dental insurance. It could be a PPO plan, which means it is a preferred provider insurance plan. This type of plan will pay per procedure to the dentist of your choice. Somebody who participates with the plan would get paid a certain agreed amount for a particular procedure, and you are not really assigned to any particular dentist. There are plans called HMO or DHMO plans. These plans usually have you assigned to a particular dentist and are usually not favored by patients or doctors. This is because the doctor you are assigned to will get a small monthly payment whether you go or not, which is often insufficient to afford treatment. As a result, patients often have difficulty finding a provider that can see them in a timely manner, with appointments booked months in advance. With HMO or DHMO plans, you cannot go outside the assigned dental office or you have no benefits at all.
Do I have an annual maximum?
Yes, you do. There's a certain amount of money each year that the insurance company will allocate based on your policy. You have an agreement with the insurance company that they will provide payment for your dental needs up to a certain amount, usually about $1,000 to $2,500. It's not unlimited; there's always a limit to how much the insurance company will spend on your behalf.
What is an annual deductible?
Each insurance requires you to spend the first $25, $50, or $100 as your annual deductible, meaning yearly deductible. After you pay this, your maximum for the year will be covered by the insurance company, but they often complicate it further by categorizing procedures. Preventative procedures like x-rays, doctor examinations, or prophylaxis cleanings are usually covered at a hundred percent after the deductible. If it's a PPO plan, preventative procedures are covered, but HMO plans might not pay anything to the dentist under the contract, although it's agreed that the dentist would do those procedures for you.
What are basic procedures?
Basic procedures include things like fillings. Most insurance covers it on about an 80-20 basis, meaning 80% is covered by insurance and 20% is your co-payment. This is still within whatever your annual limit is and after you pay your deductible. Insurance companies assign an arbitrary number to each procedure and agree to pay 80% of that number. If the dentist participates with your insurance, then it is an agreed amount. If not, you might pay the entire cost yourself and get reimbursed or there might be an agreement where the dentist gets 80% from the insurance, and you pay the rest.
What about major procedures?
Major procedures are usually covered at 50% by PPO plans. The insurance covers half of the agreed amount with the dentist or the contracted amount under your contract. If a procedure costs $100, they would pay $50, even if the real cost is more than $100, meaning you would be responsible for the rest.
Do major procedures require pre-authorization?
Not really, but the insurance company would want you to ask your dentist to pre-qualify for the procedure. They want a pre-authorization to be sent even though it's not technically required, to delay the process and potentially make you forget about the procedure, saving them money.
What if I need the procedure done over?
If you need re-treatment, such as redoing a failed root canal, most insurance companies will specify that it is either not covered or would require pre-authorization. The initial procedure must be done more than five years ago, typically specified as 60 months. Only after five years and one day can you request coverage, but they are generally not motivated to pay for re-treatments.
Are cosmetic procedures covered?
Many procedures, not necessarily cosmetic like implants, may be classified as cosmetic and not covered. Even if an implant is not in a cosmetic zone, it's often classified as cosmetic. Similarly, orthodontics like braces or Invisalign are typically not covered for those over 18 or 19 years of age.
What about Medicaid and Medicaid-type insurances?
Medicaid and Medicaid-type insurances are government-subsidized and not paid by the member but by the government. Recently, you can purchase these insurances if you wish. However, government insurance has strict rules and regulations, and the doctor must abide by those. If a procedure is not covered, you may not get it done under that plan, not even at the same dentist, because they are not allowed to do the procedure.
Conclusion
So what does your plan say? Each plan is a bit different. If you have more questions about your specific plan, we check insurances for free. You can call us with your insurance, and we will find out what kind of plan it is and let you know what to do. Now is the time when new insurances are rolling in, so you can change your plan. Before purchasing any insurance, find out everything about it, and then call us. Let us know what insurance you're considering and why, and we will tell you if it's a good choice for you. Give us a call at (718) 728-3314 or find us online at alldentalneeds.com. Request an appointment, bring your insurance information, and we'll discuss it with you.