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Week 3: What Do I Need To Know About My Plan?

Welcome to Week 3! Now that we have covered the history of dental insurance as well as the different types, it time to break it down even smaller and discuss the important aspects of insurance that you need to know.


Insurance companies have their own language when it comes to describing things and unless you are familiar with the terminology they use, you may find it difficult to understand your plan. Here we will lay out common terms you may come across and what they mean:

Coverage Categories/Tiers of Coverage - There are generally four tiers of coverage or categories that services are grouped in to: diagnostic/preventative, basic restorative, major restorative, and orthodontics. The first category generally includes cleanings, exams, and x-rays as well as other services to determine what treatment is necessary. The basic restorative tier generally includes extractions and fillings and is for minor restorations. The third tier, major restoration, covers more involved procedures such as crowns, bridges, and dentures. The final tier is orthodontics which deals with braces. Each tier generally has its own coverage rate.

Coverage Rates/Percentages - The percentage of a given fee that the insurance plan will pay for a given service. This usually depends on what tier the service falls in to. Generally, most plans follow a 100/80/50 structure.

Exclusions - Services that are not considered benefits under your plan contract (a common example is night guards).

Frequency/Limitations - Every plan has specific limitations which govern what will be approved and paid for by that plan, as well as what will not. The most common type of limitation is frequency. Each service has a set frequency (time between services) and if you go over it, your plan will not cover the service. This is most frequently encountered with cleanings and exams.

Alternate Benefit - When a specific service is not approved by the plan, they may consider another service in its place (usually one of lesser cost). In the case of an alternate benefit, the insurance still covers a portion of the procedure, and the patient must make up the difference in cost.

Downgrade - A downgrade is a type of alternate benefit that is generally used to refer to fillings. If a plan downgrades, it means that for certain teeth and surfaces, an alternate benefit will be applied (this usually means that if you receive a composite filling on a back tooth, the plan will only pay their portion of the cost as though an amalgam filling was done).

Amalgam - Generally used to refer to fillings, this type of restoration uses silver as the

bonding material.

Composite - Generally used to refer to fillings, this type of restoration uses composite

or resin-based material so the finished product is tooth-colored.

Tooth Surface - This lets the insurance company know how much of the tooth was

affected and restored. There are a maximum of 5 tooth surfaces per tooth and indicate

where a restoration was performed.

Service History - Anything a patient has had performed and paid for by the dental plan will show in their service history. Usually, if you change insurance companies, your history will start from scratch.

Plan Year - The 12 month period that your plan uses to determine your coverage. The vast majority of plans run on a calendar year (Jan 1-Dec 31) but some plans will begin your plan year on your effective date (for example Oct 1-Sept 30). This is the cycle of your benefits.

Claim/Claim Form - The document sent to the insurance company which outline the services performed for each patient.

Explanation of Benefits (EOB) - A report that is sent to both the dentist and the patient which outlines which services were charged as well as the details of the payment and/or the denial for each service.

Submitted Fee/Office Fee - The amount the office charges for a given service/procedure.

Allowable Amount - The highest amount that the dental plan will pay for a given service.

Covered Amount - The amount that the dental plan will consider for a given service. This is sometimes different from the allowable amount due to factors specific to the plan.

Usual, Customary, and Reasonable Fees (UCR) - A fee table which varies by ZIP code and is used to determine a dental plan's allowable amount in a given area.

Copayment (Copay)/Coinsurance - The amount that is owed by the patient for a given procedure..

Deductible - An amount that the patient must pay before the insurance benefits kick in. This generally only applies to the second and third tier of coverage.

Annual Maximum/Annual Limit - The majority of plans have annual maximums in the $1000-$1500 range. This is the cap that the dental insurance will pay up to per patient per plan year. Just because you have that maximum to use, doesn't mean that you are guaranteed coverage up to that amount.

Annual Rollover - If you do not use your full annual maximum from the previous year, an allotted amount may rollover into your next year of coverage. These amounts are usually capped.

Waiting Period - A period of time that must elapse before you become eligible for other tiers of service. This usually applies only to the second and third tier.

In-Network/Contracted/Participating Dentist - A dentist who has signed a document agreeing to follow the rules and regulations in regards to rate structures of a given dental insurance plan.

Network Savings/Write-Off - The amount that is written-off (not paid by the insurance plan or by the patient) and marketed as a benefit for seeing an in-network dentist.

Out-Of -Network/Non-Contracted/Non-Participating Dentist - A dentist who has not signed a document agreeing to follow the rules and regulations in regards to rate structures of a given dental insurance plan.

Dual Coverage - When a patient has two or more dental plans that they are enrolled in. This is most commonly the case when each spouse has dental insurance and they are covered under their own as well as each other's.

Coordination of Benefits (COB) - Regulations about how benefits will be determined if there are two or more plans. This covers determining which plan will be primary and which will be secondary, as well as what the secondary will be mandated to pay.

Subscriber/Enrollee/Policy Holder - The person who holds the dental insurance policy. This is usually the employee if with an employer-sponsored plan, or the individual who took out the policy on a private plan.

Dependent/Beneficiary - The person(s) who is covered by a dental insurance policy which is held by someone other than themselves (ie. a spouse or children).

Provider - Any person who is performing a dental service for you, although generally used interchangeably to refer to a dentist.

Pre-Treatment Estimate - A claim sent to the dental insurance to indicate what procedure is proposed in order to determine what their payment will be.

Fee Schedule/Table of Allowance - A type of plan which covers 100% of all procedures, but at previously set rates for that specific plan. The patient is often responsible for the difference between the fee schedule rate, and the allowable amount.

Code/ADA Code - A four digit number designated to each service and procedure to make it universally recognizable.

What Does It All Mean For Me?

When you are signing up for your dental insurance, or considering switching, we suggest you ask yourself these questions:

1. Do you anticipate that you or any of your dependents will need significant dental work in the near future?

2. Are you willing to pay a higher premium to receive better rates?

3. Do you have a dentist that you absolutely love? Do you know which plans they accept and/or are in-network with?

Once you have those answers, focus on these main aspects of coverage to determine which plan may be best for your situation:

1. Coverage Rates - If you only ever see your dentist for two cleanings a year and you are taking excellent care of your teeth, chances are you can get away with a plan that has lower coverage for restorations, thus saving you money in premiums. If you often need fillings or know that you will need a crown, it may be in your best interest to look in to a plan with high rates for restorations so you will pay a lower copay. Just be careful about...

2. Annual limits - If you need a lot of work and you chose to go with a higher coverage rate for restorations, be aware that the annual limit may be reached much quicker and will still limit the amount of work you can afford per year.

3. Waiting Periods - Though more common in private plans, a long waiting period may also affect your decision to choose a particular plan. Insurance companies don't like people signing up, getting a bunch of work done, and then disappearing so be cautious about waiting periods if that's your intention.

4. Frequency - If you have a job that requires your dental appointments to be flexible, you may want to choose a plan that allows cleanings two times per year, rather than ones limited to waiting a minimum of six months between visits.

If you are having trouble deciding, give us a call and we will do our best to talk you through it!

Next week we will look at the numbers to help you understand how some of the terms listed above interact to determine what your insurance will actually pay, and more importantly, how much of a bill you may be stuck with.

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