Posted on 12/1/2019 by Dr. Seth Senestraro
|At Senestraro Family Orthodontics, orthodontist Dr. Seth Senestraro understands that trying to make sense of the confusing mix of abbreviations, acronyms, coverage limitations, and copay options that make up your dental insurance policy can often seem like it requires a decoder ring. Fortunately, trying to understand your policy doesn't have to become a head-spinning ordeal. Here's what everyone should know about dental insurance.
Know Your Acronyms
The majority of dental insurance plans fall into one of two categories: HMO (health maintenance organization) or PPO (preferred provider organization) plans. However, you could be enrolled in either a DMO (dental maintenance organization) or a DPO (dental plan organization), so know your acronym before scheduling a dental appointment. If you don't know which category your coverage falls into, it should be printed on your insurance card.
Share When Scheduling
When scheduling an appointment, make sure to share the type of insurance plan your coverage falls under in addition to the name of your insurance provider with the dental office to ensure your coverage will be accepted. While a dentist may accept PPO plans from a specific insurance provider, for example, they may not accept HMO plans from that same provider. Stating the name of your insurance provider and the type of coverage you have will remove any potential confusion later on.
Know Your Limitations
Despite what many individuals assume, dental insurance plans have certain limitations that often require out-of-pocket payments to cover the total cost of any treatment received. The majority of dental treatments, such as fillings, bridges, root canals, dentures, crowns, extractions, and surgery, carry a copay.
Learn Your Percentages
The majority of dental insurance plans vary when it comes to how much of certain dental procedures they will cover. Preventative dental care treatments, for example, which includes procedures such as x-rays, fluoride treatments, check-ups, and dental sealants are often covered for between 80 to 100 percent of the cost, while major restorative dental procedures as dentures, bridges, and crown are usually only covered up to 50 percent of the total cost.
Discover Your Deductible
Most dental insurance plans feature a yearly deducible, which is the amount you need to pay each year before your coverage kicks in. In the majority of cases, your deductible will apply to all treatments with the exceptions of preventative care like cleanings and check-ups. However, plans vary, so check with your insurance carrier before making any assumptions.
Remember the Maximum
In most instances, enrolling in a dental plan doesn't mean you have unlimited care. The majority of plans cap the yearly maximum coverage offered around $1,000 to $2,500. So once your coverage limit is reached, any further payments will need to be paid out-of-pocket. Keep in mind that dental insurance is not cumulative, and doesn't carry over year-to-year.
Knowing what you'll need to pay prior to landing in the dentist's chair doesn't have to become a matter of guesswork. If you want to know what you'll need to pay following any kind of treatment, you can ask your dentist's office to submit a pre-treatment estimate (also referred to as a pre-determination or pre-authorization). Once you have that number, you can schedule your dental treatment based upon your available budget.
Become Your Own Advocate
The responsibility to know the limits of your dental coverage falls on your shoulders. While your dental office can offer some assistance when it comes to interpreting your coverage, you will ultimately be the one held accountable for anything your plan won't pay for in the end. To avoid any confusion, contact your dental insurance provider either online or by phone to have any questions answered in advance of scheduling treatment.
Some Treatments not Included
Having dental insurance doesn't entitle you to receiving certain types of treatment. It's not uncommon for policies to require you to pay for cosmetic treatments like teeth whitening, caps, and implants out of pocket. This is another reason why knowing your policy in advance can prevent any unwanted surprises when it comes time to pay.
Not All Dentists Accept Insurance
While it's become very uncommon to find an orthodontist that doesn't accept dental insurance, there are still some practices that accept few or no dental plans. Make sure to ask in advance if a dental office accepts insurance rather than just assuming to avoid any potential confusion.