Who Pays For What? Dental Insurance And You

  • June 1, 2016

All things considered, insurance is a great thing. Sure, paying the premiums each month gets old, and there’s always someone with a story about how some insurance company refused to pay. That can happen when you don’t know how insurance works. Some people think that insurance pays for everything, or that there are no limits.

Why do people not know more about something so important? Often it’s because there are so many confusing terms and exceptions.

Dental insurance is no exception, since it uses a lot of the same terminology. To get the most out of your insurance, you must know how insurance works.

First, here are ten terms you must be familiar with in order to understand your dental insurance.

 

  1. Benefit period: how your dental insurance company defines a year. Most of the time, your benefit period will be the same as the calendar year; the plan officially ends on December 31st and starts again on January 1st. But if you started coverage in May, your benefit period might run May 1st through April 31. This is important because most insurance plans limit how often you can get certain dental treatments each year.
  2. Deductible: the amount you have to pay each benefit period before the company starts paying for dental treatments. If your deductible is $500, expect to pay $500 before your insurance starts working for most treatments. The possible exception is preventive care.
  3. Copay: an amount you have to pay each time you visit our Honolulu, HI dental office. This is normally separate from your deductible, meaning paying a $20 copay won’t do anything for that $500 deductible.
  4. Coinsurance: a percentage of the cost for treatment that you still have to pay. If you have a plan that says it will pay 80/20 for crowns, the insurance pays 80% of the total cost and you pay the remaining 20%. Keep in mind that this happens only when your deductible has been paid.
  5. Preventive care: dental treatments designed to prevent big problems that require expensive treatments. Because this helps keep cost lower, many insurance plans will pay 100% of preventive care, even if you still owe some of your deductible. However, preventive care is usually limited to a few times each benefit period.
  6. Waiting period: Time you have to wait before the insurance company will pay for certain treatments. If your plan has a 12 month waiting period for implants, you would have to pay 100% of the costs for dental implants before that time is over. This prevents people from hurting their teeth, suddenly buying insurance, and getting huge work done.
  7. Network:a list of dentists that agree to lower their prices in return for insurance companies encouraging people to visit those dentists. This can be called a PPO network. If you visit a dentist who is not part of this network, your company will usually increase your coinsurance.
  8. Contracted fee: The amount a dentist has agreed to charge for a particular treatment. This is often part of being in a network for the insurance company.
  9. Out-of-pocket maximum: The most you will have to pay each benefit period. Any dental costs above that maximum will be paid by the insurance company. However, there are usually several disclaimers and conditions.
  10. Exclusions: Dental treatments that the insurance company will not pay for. For example, many insurance plans do not cover cosmetic work, so a plan might exclude teeth whitening.

 

Now that you know the basics, how can you get the most out of your insurance plan? Here are some tips.

 

  • Call our office at 808-797-3680 to make sure we accept your insurance plan. However, we accept all local Honolulu dental plans.
  • See what treatments your plan defines as preventive. Then determine how many you can have per benefit period and when that period begins and ends. If you get two exams and X-rays per calendar year, make sure you get what you’re already paying for.
  • Look for your coinsurance and copay rates for different treatments. Many companies pay differently, such as requiring a 10% coinsurance on fillings but 20% on crowns. That extra 10% can make a big difference.
  • Make sure you know how your plan defines the benefit period and waiting period. You don’t want to schedule a treatment only to find out your plan won’t cover any of it.

 

At our Honolulu, HI dental office, our office staff will work with you and help navigate through your insurance plan details. And if your plan won’t cover something you want done, we also work with CareCredit to provide low- and sometimes zero-interest financing for dental care. Call us today at 808-797-3680, or fill out this online questionnaire, for your next appointment.