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Scott Stephens, DDS
A Great Dentist

New Year, New Insurance

December 22, 2020
Posted By: Lauren M.

Each insurance company has its own rules, regulations, and stipulations that come with signing up for their plan. Our first piece of advice is to thoroughly look at and understand your dental insurance plan. If you have any questions, contact your dental insurance provider, your employer, and or your preferred dental office. Often, your dental office will be able to answer the most questions and explain them thoroughly since there is a high probability that someone else also has the same company and plan.

Many insurance plans start on January 1st and last throughout the year. This allows the insured to plan and maintain what services are done and when. However, this can be difficult for the insured if they have more than their maximum cost of treatment. The best thing to do in this situation is to ask your dental offices’ Patient Care Coordinator(s) or Insurance Specialist(s) to determine an estimate for the entire treatment plan. This way you and your dentist can schedule the most important treatment first and determine what would be the most cost-effective. Also, insurance benefits and remaining coverages do not rollover. Therefore, it is important to weigh your options when choosing insurance and be sure to get your biannual cleanings and checkups.

It is important to note that all this information applies to General Dentistry. Specialists like endodontists, orthodontists, and oral surgeons will come with their own coverages and will have their own costs and regulations within covered plans. When needing treatment from specialists, it is important to know exactly what is being done and understand the cost breakdown when seeing these kinds of treatment providers.

Dental insurance companies do not typically require a copay, but some do. However, almost all dental insurance companies require a deductible. A deductible collected on a one-time, yearly basis for basic and major services. Deductibles can range from $25-$50. An individual deductible is how much must be collected on a single person for their service year, while a family deductible must be met for everyone covered under the subscriber’s name before individual treatment can begin. Another aspect of dental insurance to be familiar with is whether your dental insurance company requires a waiting period. This means that, based on certain benefit levels, you must wait a certain amount of time before using that benefit level. Waiting periods can be anywhere from 3-12 months. Waiting periods generally only apply to basic and major service codes.

Each dental plan follows a format with three main benefit levels based on specific codes. Coding is how dentists, dental offices, and dental insurance companies organize and set prices for services. The first is your Preventative/Diagnostic codes which include your normal visit to a dental office: cleanings, x-rays, and exams. Preventative/Diagnostic codes are normally covered at 100% meaning that the patient will have no out-of-pocket costs up to a certain frequency. Most dental insurances allow up to two cleanings a year and any more would result in an additional cost to the patient.

The next benefit level is Basic. These services include fillings. Fillings, other than cleanings, are the most popular dental codes. Our office uses a composite filling because of its durability and strength. Composite fillings generally have four codes based on the location of the cavity in the mouth and on the tooth with varying costs due to time and materials used. Insurance companies usually cover 80% of these charges meaning the patient only pays 20% out of pocket, but basic and major services are when your yearly deductible must be paid.

Finally, major services are your crowns and build-ups. Crowns are done when the enamel structure of a tooth cannot be fixed with just a filling and a more permanent solution is needed. Major services are usually covered at 50% meaning the patient only pays 50% out-of-pocket for the procedure. Major services are going to be the most expensive of all the benefit levels, excluding orthodontics, implants, or cosmetics.

Our office also realizes that dental insurance is a privilege, yet good oral health is a necessity for overall health and longevity. There are alternative options to still make the best of whatever your situation is that our office partakes in. First, we do accept health-related credit cards like Care Credit and Lending Club. Plus, our practice offers in-office insurance through Bento that gives 15% off our normal office prices as well as the option for remaining payments to rollover.

All in all, if you have any questions or concerns while picking dental insurance, call your preferred dental office to get all your questions answered. Most offices work with the main dental insurance carriers and are always willing to give you the information you are seeking so you can make the absolute best decision for you and your loved ones.

Words and Definitions:

Copay: an amount you are required to pay to a provider before your insurance will cover the service or treatment

Deductible: the amount you pay out-of-pocket each year before your plan begins to pay for covered dental treatment; does not usually apply to preventative/diagnostic codes

            Two types: individual and family

Waiting Period: the amount of time you must wait before using a certain benefit level

Benefit Levels: these are how services are categorized based on their codes and set price; each is covered at a certain percentage          

Fee Schedule: the set price an insurance company is willing to pay for services. These differ with insurance companies and are typically different than what your dentist office charges

Maximums: the amount your insurance is willing to cover for the year. This ranges from $500-$2000 (can be more) and your yearly cleanings and other preventative services do apply

Explanation of Benefits (EOB): an overview of the services provided, their cost, and how much is paid to the provider

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