5 Questions You Probably Have About Dental Insurance

*This post is not intended to be legal or professional advice about your insurance plan. It is intended for information purposes only. If you have specific questions about your dental insurance plan, contact your insurance company or HR representative at work.

5 Questions You Probably Have About Dental Insurance

By: Bryan Mansfield, Office Manager at Nampa Dental Health Center

When it comes to money, most of us are interested in knowing why we owe the amount we owe. But sometimes, when it comes to insurance, we throw up our hands because it seems so complicated. And it is. Here are 5 questions to consider as you make decisions about dental insurance:

1. Is my dental provider in network with my dental insurance? Dentists can choose to join a network of dental providers by establishing a contract with an insurance company. Part of that contract is an agreement between the dentist and the insurance company to establish a “fee schedule.” A fee schedule is a complete listing of fees used by insurance companies to determine how much they pay dentists for dental procedures. When a dentist is “in-network” with an insurance company, it typically means that the dentist has agreed to accept the insurance company’s fee schedule and not charge the patient the difference between the office fees and the insurance fee schedule. For most people, this is a deal-breaker when it comes to selecting a dental provider. If the dentist is not in network, they find a different one. But should it be an automatic deal-breaker? Not necessarily. It depends on the cost difference between in-network and out-of-network providers (which can be minimal or significant depending on the plan) and how much you like your current dental provider.

2. How will my insurance company calculate my deductible and co-insurance portion? Co-insurance usually refers to the amount the patient will pay after insurance has paid for its portion. The average deductible for dental insurance is between $25-$100 per individual. This is the amount of money that you must pay before your dental insurance will kick in and pay its portion of dental services. Deductibles must be paid annually per individual. Typically, deductibles are waived for cleanings, x-rays and other preventive services. A simple example below will help illustrate how insurance companies apply the deductible.

Example: John Smith needs a crown, which costs $999.00. But with his in-network provider, the cost is reduced to $975.00. Insurance will pay 50% of the crown, but only after the deductible is satisfied. If the deductible is $50, we want to know how much the insurance company will pay:

$975  (contracted fee)
    -50 (deductible)
   925 * 50% = 462.50 (Insurance company’s portion)

The insurance company will pay $462.50 toward the procedure. The total procedure cost is $975.00. So the co-insurance portion (the amount the patient will need to pay), including the deductible, is $536.50.

3. How do dental insurance maximums work? Typically, dental maximums are between $1,000 and $2,500. This is the total amount an insurance company will pay for dental care in a given year. I’m aware of no instance in which an insurance company will exceed this amount in a given year. It’s important to be aware of when your benefit period ends (and your maximum renews). Sometimes it’s helpful to think of dental insurance maximums as an annual gift card. Once benefits run out, the plan is “empty” until the benefit renewal period when the maximum resets.

4. Who is the plan subscriber? There are different terms for each person covered under an insurance policy. Subscriber, spouse, and dependent are the most common terms. If the insurance is through an employer, the family member whose employer provides the plan is the subscriber. If it’s an individual plan, the subscriber was established when the plan was created. This is usually the person who pays the insurance premium. The subscriber’s family members covered under the plan are either “Spouse” or “Dependent.” The reason this matters is because in order to answer most questions about insurance benefits, insurance companies need the Date of Birth of the Subscriber and Social Security Number or Subscriber ID Number. Without that information, they won’t be able to release information to a provider and, in some cases, even a dependent on the plan.

5. What is a pre-authorization and why should I submit one? In addition to submitting claims for work that has already been done, your dentist can submit a pre-authorization request for a treatment plan for future dental work. Why? Because it allows the insurance company to give an estimate of coverage before the treatment is completed. This is usually recommended for all major treatment such as dental implants, crowns, and other major services. The downside is that you can’t expect a quick answer, and most pre-authorizations come with the disclaimer that they’re not a guarantee of benefits. It takes 3-6 weeks for most insurance companies to respond to a pre-authorization request.

Insurance can be complicated. Here at Nampa Dental, we make every effort to ensure that you are well-informed in order to make decisions about your oral health. Insurance is a tool that can be used to help pay for dental procedures, and understanding it will allow you to make financial arrangements based on accurate information.