Facts about the Changes in Dental Insurance Benefits

Some dental insurance benefits are changing rapidly,

Benefit coverage is a contract between a patient, the insurance company and your employer. This contract is not with the dentist.

Dental insurance companies do not inform dental offices of policy changes.

Many insurance companies are making changes in coverage for dental procedures. This is an action designed to allow insurance companies to cut their cost of providing benefits. Necessary treatment may not be covered by your insurance plan.

Ultimately, patients are responsible for payment of fees for dental treatment.

Dental benefits usually do not cover 100% of treatment cost.

We suggest that you get updated information from your insurance company before making your dental appointments.

Methods Used by Dental Insurance Companies to Contain Expenses
Some companies offer 100% coverage based on fees appropriate in 2002 (or earlier). Current fees may be higher than the coverage provided by a dental benefit plan.

Our fees are based on our clinical expertise, quality of care and materials.

A pre-estimate may be sent to your insurance company for confirmation of your coverage.

Insurance companies often return pre-estimates with requests for cheaper, alternative treatment plans.

Some insurance companies are trying to establish dental benefit programs which provide minimal coverage and limit the patient’s choice of a dentist and covered treatment. This is known as capitation.

The following list is of commonly used insurance terms which are important to know when discussing dental benefits.

ANNUAL MAXIMUM – Most insurance companies have an annual maximum amount of coverage for each patient listed under the insurance policy. This coverage may be changed and patients may not be informed.

DEDUCTABLE – The dollar amount the patient pays towards their treatment total before insurance coverage begins.

ELIGIBILITY – Eligibility determines who is covered under the insurance policy.

EXCLUSIONS – Many dental services and treatments that are clinically necessary are not covered by dental insurance. These exclusions are usually described in the patient’s insurance booklet. Due to the fact that more treatments are being excluded to reduce costs, a pre-estimate of benefits is usually prudent.

CO PAYMENT - or “Out of Pocket Portions” is part of the treatment fee not covered by dental insurance. The insurance company will pay a certain percentage of the treatment, but they rarely cover 100%.

DUAL COVERAGE – is when both spouses are covered by different insurance plans. The insurance companies coordinate the benefits so that the patient does not receive more than 100% of the fee guide, which is used by the insurance company towards the cost of treatment.

ASSIGNMENT – of insurance is when the patient signs a section of the insurance form, which allows the dentist to receive payment directly from the insurance company, instead of having the patient pay the dentist and then wait for their insurance claim. However, patients are responsible for the “Out of Pocket Portion” at the time of treatment and any treatment that may no longer be a covered expense. Insurance companies now often send payment to the patient. This should be forwarded to the dentist as soon as possible.