Since 1992
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By Jay Wietecha, D.M.D., M.A.G.D.
Smile Solutions of Maine
“I just got a new job that has an insurance benefit, and I am finally ready to start fixing my teeth. It’s been many years since I have last seen a dentist.”
We come across this situation often with new patients. Patients sometimes are not aware there can be some limitations to dental insurance coverage, misleading a patient into thinking all their dental care will now be covered.
First off, many insurance companies have a waiting period at the beginning of the policy stating when certain procedures can be performed. Typically, major restorative work — such as crowns — are not covered until this waiting period is complete; however, cleanings and exams are usually covered right away.
Also, most insurance policies have a maximum annual expenditure amount the insurance will cover. This means if you go over this amount in a calendar year, the remaining services will be completely out-of-pocket. Patients are sometimes caught off guard that these maximum limits could be reached fairly quickly, depending on the complexity of treatment.
In addition to maximum allowed amounts, it is important to understand that different dental procedures have different coverage percentage amounts. For example, preventative services like cleanings are usually covered at 100 percent. Major restorative care like crowns and bridges tend to fall in the 40 to 50 percent coverage range.
These coverage’s are for the amount dictated by your specific insurance company’s fee schedule, not necessarily the dental office fees. The difference between the two fee schedules adds to the “out-of-pocket” expense for the patient.
The specific details about insurance coverage and limitations are negotiated between the patients’ employer and the insurance company. The best way to find out more information is to read through your benefit package or discuss things with your employer.
To help you fully understand what your specific benefit will be on each procedure recommended by the dentist, our team can file a predetermination with your insurance company for you.
This asks the insurance company to outline for you the exact coverage and expenses of your plan for each specific procedure. This will help you better understand the financial impact of dental care now that you are ready to take steps forward for a healthier mouth.
