Will My Insurance Cover That?

Will my insurance cover that?

This is a commonly heard question at my office. The flip answer to the question is "it's your insurance, why are you asking me?". This answer doesn't win many friends so I generally start asking questions about the insurance. I am constantly amazed at how little people know about this valuable benefit and how often people fail to use it. To me it's like going to the store and buying groceries, paying, then just leaving them there and going home. It almost seems as if, ahem, people were being kept deliberately in the dark about this benefit, but back to the question. Will your dental insurance cover your dental treatment? The answer is yes, maybe, sort of, sometimes, no. Not very satisfying is it? This confusion results from a basic misunderstanding about the nature of dental insurance. and my first important point.

Dental insurance is NOT insurance.

Insurance is money paid to protect oneself from unforeseen and financially catastrophic loss. Dental needs happen to everyone. Most people visit their dentist twice a year like clockwork...hardly unforeseen and, while never welcome, dental problems can rarely be seen as financially catastrophic.

Your Employer views your "insurance" as part of your pay.

Dental benefits are not required by the government. Your employer buys them for you because it is cheaper than paying you more money plus taxes.

The Insurance Company Does Not Want To Pay.

Let's face it, the insurance company is in business to make money just like everyone else. The more money they can avoid paying out in claims, the better their bottom line looks at the end of the year.



Over the years, different types of dental benefit plans have been developed. These are summarized as follows:

Indemnity Plans - Traditional dental benefits. You choose your dentist and the insurance company either pays benefits to you or the dentist. Benefits are limited by: Yearly maximum ($500.00-$2,500.00), The type of service, and UCR. UCR or usual, customary, and reasonable fee is actually none of these and can vary greatly from region to region, between zip codes in a region, between insurance companies, and even among different plans by a single insurer! There may be a period of time that you must be on the plan before it will pay for some procedures. There is usually a yearly deductible which you must pay before benefits begin. This type of insurance most often pays 100% of preventive costs...cleanings and X-rays, 80% of regular care...fillings, root canals, extractions, and 50% of major dental...crowns, bridges, and dentures. Sometimes they don't pay this well. Rarely, they may pay a little more. Your insurance may not pay to redo work within a certain span of time, so if you get an inlay(major work) and break another piece of the tooth next year(honest, sometimes this just happens) your insurance may not pay. Your insurance may not pay to replace a tooth that was already missing before you started on the plan. Your insurance may not pay for work that it considers to be purely cosmetic. Your insurance company may decide that you don't actually need a procedure at all and refuse to pay or pay for an alternate procedure. (note that if a dentist does one procedure and charges for another it's called fraud).The list goes on and this is why it is imperative that you carefully read your benefits booklet. If you don't have one, get one. Keep in mind that you are ultimately responsible for any charges that your insurance doesn't cover. It is not your dentist's job to keep track of this stuff for you although many do try.



PPO or preferred provider organization. Here the dentist agrees to charge a pre-set fee(usually discounted). The patient still has to pay a part, but it is usually smaller. In return, the insurance company actually sends new patients to the dentist. This is especially good for dentists who have trouble getting new patients. The cost to insurance company, employee, and employer is lower. DHMO's or Dental HMO's are not dental insurance at all. Under these plans you must choose a participating dentist to receive benefits. These plans are of 2 types.

Capitation: The dentist receives a small monthly payment for each patient he is assigned. He is not paid for any preventive or restorative treatment he provides by the insurance company except for that capitation (by the head) payment which he receives whether he treats you or not. Since treating patients costs the dentist money, he fares best if he does not treat his patients at all. This is a clear conflict of interest. I consider all of these plans to be fundamentally dishonest and I do not participate in any of them.

Fixed fee for service: The plan provides a fee schedule for the patient that they have arranged. This fee schedule sets the fees so that it is in the best interest of the dentist to cut costs in order to make a profit. It pays to use low quality low cost laboratories because the use of a high quality lab may eliminate any profit a dentist might have.





Direct Reimbursement Plans are the newest entry into dental care cost assistance and hold great promise. The American Dental Association is promoting Direct Reimbursement Plans and provides and assistance to employers in establishing these plans. The insurance companies are bitterly opposed to them, largely because they eliminate the insurer altogether. In Texas the Texas Dental Association has established Paid Dental. The patient pays for his treatment (many dentists will accept a post-dated check) and brings the paid receipt to his employer to be reimbursed in whole or in part. The percentages of reimbursement are based on the benefits used. A typical plan might pay 100% of the first $200 of dental expenses, 80% of the next $500 and 50% thereafter until an annual maximum of $1000 is reached. Because the patient's share of the expense increases as more benefits are used, the patient is discouraged from overuse of the benefits and encouraged to use his shopping skills to get the most for his and his employer's money. Any additional cost incurred by allowing the patient to control his own treatment is more than made up by eliminating the insurance company's processing costs and profits. These plans may hold the key to providing effective dental cost assistance while providing employers with savings comparable to the managed care scams and maintaining real benefits to the employees.