Making You Smile Cosmetic Dental Studio Entrance on E 36th St

The Ultimate Guide to Dental Insurance

Dental Insurance 101

Different Types of Insurance and Different Types of Providers – How to Choose?

At Making You Smile Cosmetic Dental Studio, we hear a lot of questions from our patients; and some of them become so common, we thought it would be beneficial to provide you with some further understanding of your dental insurance and provider options. We’ll cover the basics and then offer our recommendations for what can suit you best. Our Patient Care Manager has 15 years of experience with dental insurance and we process thousands of claims every year.

What are the different types of dental insurance?

There are four (4) different types of dental insurances:

  • PPO (Preferred Provider Organization): A PPO plan is the most common and provided by most private employers. You tend to receive the best quality of care within a PPO, because most dentists participate with this kind of insurance, thus creating healthy competition for new patients. You have the freedom to choose your provider, however, if you choose an out-of-network/non-participating provider you will pay more.
  • EPO (Exclusive Provider Organization): An EPO plan is the same as a PPO, however, if you choose an out-of-network/non-participating provider your insurance will pay no benefits.
  • DHMO/HMO/Medicaid: These styles of plans are usually difficult for patients to find an accepting provider, but is a good option for basic preventive care. You’re usually assigned a specific provider by your insurance company and you will receive benefit/coverage only if you see your assigned provider.
  • Employer table of allowance fee schedule: Your plan will help you for each procedure up to a pre-set schedule amount.

What are the different type of dental insurance providers?

In-Network vs. Out-of-Network:

  • In-Network: Also known as “participating dentists”, an in-network dentist has agreed to a discounted rate with the insurance companies, which is typically less than their standard office fee.  For all covered procedures, the dental office can only bill based on the reduced rate. The outcome of this arrangement benefits the patient the most, because your out-of-pocket expense is based on a reduced rate.
  • Out-of-Network: Also known as “non-participating dentists”, an out-of-network dentist charges on Usual, Customary and Reasonable fees based on their own fee schedule.  These fees are not discounted rates and therefore, your out-of-pocket expense would be much higher. Sometimes the dental office will bill your insurance to help assist in the payment of the treatment, however they will collect from you the unpaid balance from your insurance

At Making You Smile we are an in-network/participating provider with a wide range of PPO, EPO and employer table of allowance providing you with highest quality of care while maximizing your insurance benefits. Get in touch now for your Customized plan benefit review”.

How Does Dental Insurance Work?

There are different parameters to be aware of to best understand how dental insurance works. These parameters are determined and negotiated between your employer (or yourself, if you purchased the insurance plan directly) and the insurance company. The outcome of the negotiation is a specific “insurance plan” that is given a “group number”. The insurance plan is an agreement between the employer and insurance company regarding your dental benefits.

As your dental office, it’s our responsibility to do everything we can to facilitate your understanding of your insurance plan and to maximize your benefits within the rules of that plan. Though we don’t have access to the complete contract defining the rules of your insurance plan, we do our best to inquire on your behalf so we can clarify any questions you may have.

Here are some of these parameters:

  • Maximum: This is the amount of money that the insurance company will pay out in benefits in a given year. Most often it is $1,000 or $1,500 and may vary by plan.
  • Calendar Year or Fiscal Year: This is the schedule that the insurance company will pay out your benefits. The majority of plans run January to December of the same year or on a calendar year schedule. Having a dental insurance plan that operates on a fiscal year is perfectly fine, just be aware of when your plan begins and ends.
  • Deductible: This is a set amount (typically $25 to $200) the patient pays before insurance company pays out certain services.  Typically the deductible is per individual and must be satisfied on a yearly basis before insurance will cover larger portion of your dental fees.
  • Copayments: Depending on the type of dental insurance you have, your insurance will cover different dental procedure at a different percentage rate. Examples include (based off the reduced rate fee schedule of an in network dentist):
    • Cleaning of healthy gums, x-rays and exams are typically covered at 100% (you pay $0 if you have no deductible)
    • Fillings are usually covered at 80% (typically you pay the deductible + 20% of the filling)
    • Crowns are typically covered at 50% (typically you pay the deductible + 50% of the crown)

Frequency & limitations:

Depending on your employer’s generosity your insurance plan will have some limitations:

  • Yearly maximum: This is the maximum amount of money that the insurance company will pay for you on a yearly basis. After the yearly maximum amount has been met, an in-network dentist will continue to charge you at the reduced rate, allowing you to continue to save money.
  • Non-covered procedure: Usually cosmetic dental procedures are not covered, such as teeth whitening, veneers, and in some instances, dental implants.
  • Downgrading or alternative benefits: Some insurance plans will pay for the least expensive option to fix a particular problem. For example: the insurance company will pay for a mercury filling (silver filling) instead of tooth colored filling (composite filling) or a metal cap instead of a tooth colored ceramic cap or a removable bridge to replace a missing tooth instead of dental implants. These less expensive alternatives will usually “solve” a patient’s needs, but many patients opt for the nicer treatment options for future convenience, dexterity, and aesthetics.
  • Waiting period: Insurance will not cover certain procedure until your policy has been in force for a certain period of time, usually 6 to 24 months.
  • Exclusions: Insurance companies will sometimes not cover certain procedures to fix problems you had before getting the insurance (known as a pre-existing condition). A common example dental offices see is when a patient has a tooth removed before their policy is in force, the insurance company will typically not cover the costs of replacing that tooth for you (missing tooth clause).

Would you like to know if your plan will help with your first dental visit or first dental consultation?  Do you want to know exactly what your plan covers? Email, text or call us with your insurance card details and we will find out for you. Or simply fill out our contact form.

Dental Insurance: Q & A

What are insurance plans?

An insurance plan is the combination of the rules governing your dental insurance such as deductibles, copayments, and limitations. These rules are determined and negotiated between your employer (or yourself if you purchased the insurance plan directly) and the insurance company. The outcome of the negotiation is a specific “insurance plan” which is given a “group number”. The insurance plan is an agreement between the employer and insurance company on your behalf regarding your dental benefits.

Who decides what those parameters (deductible, copayments and limitations) are?

Your employer meets with the insurance company and chooses a dental plan with certain rules. Sometime the employer chooses two or three different plan to offer to their employees. During open enrollment time, which occurs with qualifying events each year, the employee can choose or change which plan they want.

Can a dental office find out ahead of treatment what the rules of my plan are?

If the policy is in force yes, absolutely. That is what dental offices can do for you. All the office need from you is the plan information, such as your “member ID” & “group number”, which can be found on your insurance card. The dental office will also need some basic information, such as your name and date of birth. Most dental offices can contact your insurance company for you to obtain the necessary information about your plan, which they can give you an overview of upon your visit.

How much time does it take to get the insurance plan details?

Insurance companies rarely have plan details online, so all of us (dental offices and patients alike) have to call the insurance company during business hours, which are usually between 9am and 5pm.  Gather as much information as possible to be able to answer any related insurance questions you may have. Having that information on hand allows for your dental office to inform you of your financial obligations before any work is done.

At Making You Smile we know how to maximize your benefits. On your initial visit we will review your benefits with you to help you understand how your plan works. Contact us now for a Customized benefit plan review”.