Know your acronyms. Dental insurance plans are generally categorized as either PPO or HMO plans, which stands for preferred provider organization and health maintenance organization. Other acronyms include DMO, for dental maintenance organizations and DPO for dental plan organization.
Include that acronym when scheduling your appointment. It’s not enough to tell the person setting up your dental appointment the name of your dental insurance company. You also need to tell them if it is a PPO, HMO or other type of plan because different dentists participate with different kinds of dental plans.
Dental insurance has limitations. Some people think that dental insurance will pay for the total cost of their dental treatment. This is rarely the case. Most treatment, including fillings, crowns, bridges, root canal, dentures, extractions, oral surgical procedures, and gum therapy often require an out of pocket expense (also referred to as a copay) in addition to what the dental insurance covers.
Learn your coverage percentages. Most dental insurances cover different dental procedures at different rates. For example, preventive care, which includes cleanings, check-ups, dental sealants, x-rays, and fluoride treatment are often covered at 80-100%, while major treatment like crowns, bridges, and dentures are often covered at only 50%.
Know your deductible. Many insurance companies have a yearly deductible, which is the amount you have to pay before your insurance kicks in. In most cases, this applies to all treatment with the exception of preventive care like check-ups and cleanings, but plans vary so check this out with your insurance carrier.
Remember your yearly maximum. Most dental plans have a yearly maximum from around $1000-$2500. Once you hit your maximum, you are out of benefits for the year, and will have to pay out of pocket for any additional dental treatment, even cleanings. Also keep in mind that dental insurance is not cumulative, so what you don’t use in a year is gone and can’t be applied to the following year.
Be your own advocate. It is really your responsibility to know the details of your dental plan. You can get help by calling your dental carrier or going online to get your dental coverage details, which should include a list of participating dentists and your group number. Most dental offices can assist you with questions about your insurance, but keep in mind that a busy dental office cannot always know everything about all of their patient’s insurance coverage.
You can get a pre-treatment estimate. If you want to know exactly how much you will have to pay for your dental treatment, you can ask your dental office to submit a pre-treatment estimate (also called a pre-authorization or pre-determination). Once that comes in, you can schedule your treatment according to your dental needs and budget.
Some dental treatment may not be covered. Not all treatment you may want or need will be covered by your dental plan. Treatments often not covered include cosmetic procedures and dental implants. Some plans are so limited that they only cover exams and cleanings. That is why it is important to know what treatment you need and if you have the coverage for it ahead of time.
Not all dentists accept dental insurance. Some dentists take very few or no dental plans. This means that your out of pocket expense will be higher at this dentist than with a dentist who participates with your dental plan. Even if your dentist does not participate with your insurance, you may still be able to use your insurance for partial payment. Ask the front desk personnel at your office for details.
Dr. Gordon would like to acknowledge his office manager Terry Tepper and assistant manager Jennifer Jackson for their assistance with this article.