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Have you ever really thought about the answer to that question? If you haven’t you are not alone. Many patients typically are not in tune with how their dental claims are paid or what their plans pay for. The items I have listed below are just a few little snags your employer or the insurance carrier do not explain to the insured.
- Annual Maximums: This is the highest dollar amount that your dental plan will pay during your benefit year. Most dental plans run on a calendar year Jan-Dec, however there are other plans that run on a benefit year which may be different. Any costs that rise above your annual maximum will be considered out of pocket for you.
- Preferred Providers: This term means one thing, if you see a dentist within the preferred network, which solely means they are in their network (participating dentist). If you get dental care from someone who is not in the network, your costs out of pocket will be greater.
- Pre-Existing Conditions Clause: Your dental insurance may have a missing tooth clause. For example replacing a tooth that was extracted prior to you enrolling in the dental plan benefits will not be paid.
- Coordination of Benefits or Non-Duplication of Benefits Clause: (Applies only if you carry dual insurance with your spouse): Even though you may have two dental plans there is no guarantee that all of the plans will pay for your treatment. Every insurance company handles the coordination in its own way, it is best to discuss this with both of your insurance companies for details.
- Frequency Limitations: Your dental insurance will limit the number of times it pays for certain treatments. However this should never dictate your treatment. For example, a cleaning and exam may be covered twice per plan year or once every six months (which means it MUST be six months to the date in order to receive the benefit). Be aware of how your plan plays so that you can receive the maximum benefit from your insurance.
- Not Dentally Necessary: Your insurance carrier may claim that a procedure is not dentally necessary and will not be covered. If this is the case it does not mean that the treatment was not needed. Never allow your insurance to dictate what is necessary, only you and your dentist should be making that decision. If your insurance denies treatment, you can appeal the claim.
- Downgrading: This is what your insurance company will do to reduce their cost. They may downgrade on certain treatments. For example, you may want a filling done with a composite (white) material but your insurance will only pay for a silver filling leaving the difference an out of pocket expense for you.
- Least Expensive Alternative Treatment Clause: When there are two ways of treating a condition the plan may only pay for the least expensive option. However this may not always be the best option. For example: your dentist may recommend a bridge to replace a tooth, but your plan may only pay for a partial denture.
*Always Remember that although you might be tempted to make a decision based on what your insurance will pay, remember that your health is the #1 priority. Take the time to discuss the best possible options regarding your care so that you can keep your teeth for a lifetime!
AS ALWAYS, THANK YOU FOR BEING PART OF OUR PRACTICE FAMILY!