Dental Insurance Highlights

Many patients with dental insurance believe that they are well covered when they visit, and are surprised when they learn that they have to pay more than expected, or that they are required to pay for their entire treatment. Most patients are well informed of the basics of their coverage (cleanings, X-rays, fillings, etc.), but may not know about their coverages for more intensive treatments. Ultimately, it is the patient’s responsibility to pay the final balance, so knowing the details behind your insurance coverage is a good idea. Family Dental of Palatine has provided some basic dental insurance highlights to help our patients gain a better understanding of how their insurance works.

  • YEARLY MAXIMUM – The yearly maximum is the total amount your insurance company will issue in checks to your provider during a 12-month period. If you have a maximum of $1500, it doesn’t mean that you can get two treatments for $750 each. Your insurance will cover a percentage of each treatment, and will continue to make payments on approved treatments until they reach the maximum for the year. Your benefit year does not necessary run from January through December. Be aware of exactly when your coverage year begins and ends. Unused maximums do not roll over to the next year. Some plans allow separate maximums for orthodontic care.
  • DEDUCTIBLE – Your deductible is a yearly fee paid by you. It must be paid in order for your insurance to start paying your treatment claims. This deductible is general collected by your dental office when you visit. Know what your individual and family deductibles are. Most dental insurance plans will only require you to pay your deductible when you have an actual treatment performed, and not during routine diagnostic and preventive visits (cleanings, X-rays, exams, etc.), but only when you have an actual treatment performed.
  • CROWNS PRIOR PLACEMENT – Many plans have what they call “prior placement.” This means that they will want to know when your existing dental crown was placed if you are replacing it. If the crown is less than 5 years old, they will not pay for the replacement. If you are receiving your replacement from a different dental office, the dentist will rely on your statement of when the crown was originally done, and will notify the insurance company. Many dental plans will only pay for a certain type of crown (metal, or porcelain over metal). If you want a different type of material, you will be responsible for your co-pay as well as any differences in the cost of the product.
  • FILLINGS – Many dental insurance plans will not pay for all your composite fillings. Instead, they will downgrade any fillings done on your back teeth to amalgam fillings. You will be responsible for the difference in fees between the two types of fillings. For example, if your plan covers 80% of fillings, your co-pay will be 20% of the amalgam fee, plus any differences in fees between the two types of fillings. Generally, an insurance company will pay for a filling on the same tooth every two years.
  • CO-PAY – Co-pays are the percentage of the treatment that you share in paying for your dental plan. If the cost of your treatment is $100, and your plan covers 80%, then you will pay $20, and your plan will cover the remaining $80. You can save money on your co-pay by visiting a dentist that not only accepts, but contracts with, your insurance company. A dentist in contract with your insurance company has agreed to accept your plan’s discounted fee schedule, meaning that your yearly maximum will cover more treatments.
  • FREQUENCY LIMITATIONS – Frequency Limitation indicate the number of times you can have a particular procedure performed in a year. For example, can you have two cleanings at any time during the year, or must they be exactly 6 months apart. For example, if you were to visit a dentist, and then less than 6 months later visit different dentist to have a dental cleaning, you might receive a billing statement.
  • BRIDGE MISSING TOOTH CLAUSE – This facet of dental insurance may be applicable if you had a tooth extracted years ago and left that space empty because you couldn’t afford a bridge or an implant. If your tooth was extracted more than 6 months ago and your plan has a bridge missing tooth clause, your insurance may not authorize a claim for a restoration. You will be responsible for the entire cost of your treatment.
  • WAITING PERIOD – Many insurance plans have a waiting period on major services. The amount of time varies between plans, but during this period, your insurance will only cover basic dental services (cleanings, exams, x-rays, etc.). You can only use your insurance for major services (crowns, bridges, etc.) after the plan has been in force for a period of time. Check with your insurance provider to learn your waiting period.
  • EOB – This stands for Explanation of Benefits. Check your mail for statements from your insurance company, and call with any questions about payments. Remember that you are responsible for any unpaid balance.

While we don’t know the details of your policy, we can all but guarantee that it will include one or more of the details listed above. We have provided a quick matrix to help you review everything mentioned. If you have questions about your dental insurance, you should call your insurance company to learn more and discover the details of your coverage.

YEARLY MAXIMUMThe amount your insurance will pay for a plan yearHow much is the yearly maximum? When does my plan year start and end? Do I have a separate maximum for orthodontic treatments?
DEDUCTIBLEThe amount you’re responsible to pay once a yearDo I have an individual/family deductible? How much is my deductible? Does my deductible apply to diagnostic and preventative?
FREQUENCIESHow often you can have routine visitsHow often am I allowed cleanings? If twice am I allowed anytime or exactly every 6 months?
 CO-PAYThe percent your insurance covers for a group of servicesWhat is the percentage covered for each service group?
  FILLINGSAmalgam or CompositeAre fillings downgraded on back teeth?
CROWNSDental restorations, also called “caps”Does my plan have a prior placement clause?
BRIDGE3 or more crowns covering the area of a missing tooth or teethDoes my plan have a “missing tooth clause”?
 WAITING PERIODThe time you must wait before your insurance will pay for certain servicesDoes my plan have a waiting period? If yes, how long, and for which services?

Please remember that patients are responsible for paying any charges not covered through their insurance. This includes non-covered services, deductibles, co-payments, or fees for other services or termination of coverages.

If you have any questions about our accepted insurances or payment options, please contact Family Dental of Palatine today for more information or to schedule an appointment with our dentists, Dr. Wajih Chammae and associates. If you have questions about your insurance coverages, contact your insurance provider.

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