Do you have dental insurance? Do you understand your plan? Most of our patients have questions about their plan and while each plan is unique, we would like to share with you “DENTAL INSURANCE: 101”.
You will find definitions to commonly-used terms below that may help you to better understand your plan. We also have a dedicated Insurance Coordinator that will be happy to answer any questions or to help you contact your plan for details.
Maximum – The amount that your insurance company will pay up to per calendar or benefit year. It is important to know if your plan runs January – December (calendar year) or on a benefit year.
Deductible – The amount your insurance will deduct from your benefits prior to paying for certain services. In many cases, it does not apply to preventive visits (exams and cleanings); however, some plans are changing to include preventive services and x-rays.
Copayment – The amount (usually a percentage) due to your provider that your insurance plan will not cover.
Replacement Period – The time in which your insurance company will not consider benefits to replace existing crowns, bridges, implants and partial dentures.
Missing Tooth Clause – If you have a tooth extracted prior to the start of your insurance plan and they have a missing tooth clause, you will not have benefits available to replace the tooth with a partial, bridge or implant.
Frequency – Your insurance plan allows certain procedures to be done according to their frequency limitations. Most procedures apply to the frequency limitation!
Preventive Services – Usually applies to exams, cleanings, x-rays and sealants; however, each plan is different.
Basic Services – Usually applies to fillings and sometimes endodontics (treatment of the nerve of the tooth), periodontics (soft tissue/gum treatment) and oral surgery (extractions, biopsy and bone grafting).
Major Services – Usually applies to crowns, bridges, dentures and partials; however, may also apply to endodontics, periodontics and oral surgery.
Alternate Benefits Clause – some plans downgrade certain services such as posterior (back) tooth-colored fillings to amalgam (silver) fillings and pay based on that particular rate. Some plans downgrade porcelain/metal base crowns to all metal.
Duplication Clause – If you have two insurances and the secondary plan has this clause, they will not provide benefits for any service in which the primary plan pays.
Waiting Period – Your plan may assign a waiting period for certain types of treatment. Most often, waiting periods are determined upon application to the plan so please make sure if you are changing plans that you ask about waiting periods for treatment.
