10 tips on understanding dental insurance plans
Although many employers provide dental insurance, a lot of people don’t take full advantage of their coverage. It’s similar to getting a gym membership but only showing up a few times a year. Here are some tips to help you make the most of your dental insurance benefits.
1. How to take advantage of your child’s dental annual maximum
Most dental insurance plans have an annual limit of $1,000, $1,500, or $2,000 per child each year. The insurance company will only cover treatments, including preventive care, up to this amount annually.
Unused benefits generally do not roll over to the following year, so any remaining balance is lost. Typically, these benefits reset at the beginning of the new calendar year. Click here for more information on how to maximize your dental insurance benefits.
2. Understanding the Insurance Company's Motivation
Your dental insurance is designed to help the company save money in the long run. Much like other aspects of life, it’s easier and more cost-effective to prevent problems before they arise.
This is why most dental insurance plans cover 100% of preventive care. Preventive care typically includes services like exams, cleanings, x-rays, and fluoride treatments for children.
Many insurance plans also cover other preventive treatments, like dental sealants, at 100%. Sealants are a thin, tooth-colored coating applied to the chewing surfaces of adult molars, helping to protect against cavities by filling in pits and grooves. This quick, painless procedure can be done during a regular cleaning and helps reduce the risk of future decay. Be sure to ask your dentist about sealants for your child during their next visit. Click here for more information on sealants.
3. How to Avoid having to Pay Your Deductible Every Year
Typically, when your child requires treatment within a coverage year, you’ll need to pay a deductible, usually ranging from $50 to $100. This is separate from your co-pay and only applies once per year if your child needs restorative care, such as a filling or crown, but not for preventive services.
To minimize deductible payments, it’s best to complete all of your child’s necessary restorative treatments in the same year while continuing preventive care the following year. If your child doesn’t need additional restorative work in the second year, you won’t have to pay the deductible again. However, if you spread the treatments across two years, you’ll be required to pay the deductible for each year.
4. Insurance Coverage for Fillings Is Typically Better Than for Crowns
If a dental issue can’t be prevented, it’s crucial to address it early. Many insurance plans cover 80% to 100% of the cost for fillings, while larger, more complex procedures like crowns are often only covered at 50%.
For example, with 80% coverage, a filling that costs $120 would leave you with just a $20 out-of-pocket expense. However, if the cavity worsens and requires a pediatric crown costing $240, with only 50% coverage, your out-of-pocket cost would rise to $120. Even though the crown costs twice as much as the filling, your personal expense is six times higher!
Keep in mind, choosing a filling when a crown is the more appropriate treatment won’t save you money in the long run. If the filling fails, your child will need additional procedures, and you’ll end up paying for both a filling and a crown later on. It’s better to get the right treatment from the start.
Click here on more information regarding fillings and crowns.
5. Understanding dual insurances
When a patient has two insurance plans, they often believe that whatever isn’t covered by one plan will be covered by the other. However, this is not always the case.
When a claim is submitted, it uses specific dental procedure codes. One plan is designated as the primary insurer, while the other is secondary. The claim is first sent to the primary insurer, and you’ll still need to pay any copays or deductibles. The secondary insurance won’t always cover these costs. There are some secondary plans that will only pay for things the primary didn’t cover if the specific code is included in the secondary policy or if you’ve reached your annual maximum on the primary plan.
Once the primary insurance processes the claim, it’s sent to the secondary insurer. If the primary didn’t cover a particular procedure code, the secondary plan may cover it, assuming it’s part of the policy.
6. How to Utilize a Health Saving Account (HSA)
A Health Savings Account (HSA) is not insurance, but many employers offer it as an option. With an HSA, you can contribute pre-tax dollars, which can save you money depending on your tax bracket.
For example, if you’re in the 25% tax bracket and need to cover $600 in treatment costs, you could use $600 from your HSA. Otherwise, you’d need to earn $800 to have $600 after taxes, saving you $200 by using the HSA.
The main downside of an HSA is that it requires additional documentation to prove the funds were used for medical or dental expenses. In some cases, unused funds may expire after a certain period. Be sure to check with your employer or HR department for specific restrictions on your HSA account.
7. How to Choose The Right Dental insurance Plan
If you know your child requires extensive dental work or specific procedures like orthodontics, it’s a good idea to explore dental plans that offer better coverage for these services.
Here is another post on understanding dental insurance plans.
8. Understanding the limitations that the dental insurance puts on each Procedure
Many dental patients assume their insurance covers two cleanings and exams each year, but this is somewhat misleading. Typically, insurance covers a cleaning and exam every six months. While this may seem similar, there are some important differences.
To have your cleaning covered, you must wait at least six months since your last cleaning. This means that if you visit the dentist every eight months, you’ll only receive three cleanings over a two-year period instead of four, all while paying the same monthly premium for fewer services.
Another limitation arises when a restoration needs to be replaced. For instance, if you had a filling and, three years later, new decay develops on another part of the tooth, many insurance plans may not cover the cost of a new restoration.
Please note that these are general observations based on my experience with various dental insurance companies. It’s essential to read your specific policy carefully to understand any limitations or exclusions that may apply.
9. Why does my dental insurance plan have a “waiting period”?
Having a dental insurance plan is an important step toward maintaining a healthy smile in the long run, but choosing the right package can feel overwhelming. With numerous factors to consider—such as premiums, out-of-pocket costs, and specific benefits—it can be a challenge. One aspect that many people overlook is that many plans include a waiting period.
A dental insurance waiting period is the time you must wait after purchasing your plan before coverage for certain benefits begins. This waiting period can range from 30 days to a year. While not all dental plans have a waiting period, many do.
During this waiting period, you can usually still visit the dentist for basic checkups and preventive care. Typically, the waiting period applies only to specific restorative and major procedures, such as dental crowns, fillings, extractions etc.….
10. Be careful When Selecting the Plan With the Lowest Monthly Payment
We all love a good deal, but sometimes something is inexpensive for a reason. You might come across dental plans that cover only specific or limited procedures, such as preventive care, while more complex treatments like fillings, crowns, or extractions may not be covered at all. I’ve encountered patients with insurance plans that offer little to no savings compared to paying out of pocket for treatment.
Understanding insurance can be confusing, which is why our team at Sorenson Pediatric Dentistry strive to provide clear and comprehensive information about your insurance options to all our patients.
Got questions regarding your dental insurance? Call us!
If you have any questions regarding your child’s dental insurance call our office and the team at Sorenson Pediatric Dentistry will help you to understand your dental insurance plan
Call us and schedule your child’s appointment today: (702)586-4347
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