Dental Clinic Patient Information
A brief guide to understanding your insurance coverage
- What does it mean Basic and Major Treatments according to the insurance company?
- Exams covered by your plan
- Topical fluoride application
- Dental x-rays covered by your plan
- Does my plan cover me to have teeth cleaned every 3 months?
- Assignment of Benefits
- Predetermination/ Preauthorization
- How you value your smile will make you less insurance dependent when seeking dental treatment
Before I get into dental insurances, let me introduce two terms to you. Dental plans are the insurance plans that your dental insurance companies promise to cover you under the contractual responsibility they have had with your employer or the subscriber (that is You). Treatment plans are the plans your dentist develop for you and with you and are based on your needs and desire and are meant to be the best for your dental health. Ideally, your dental plan will cover every treatment plans you need and you want. Unfortunately, this is often not the case because insurance companies are to make money, not to satisfy every need of their clients.
Typically, you and your employer pay a fixed amount of money monthly to an insurance company as the premium to have you covered for a bunch of insurances such as medical insurance, life insurance, eye-care insurance, dental insurance etc. The insurance company will then give you a booklet or brochure outlining what is covered, how it is covered, and how much percentage it is covered for a specific procedure. Generally, your dental insurance will not cover what are considered as cosmetic treatments. These treatments, for example, include the followings: tooth whitening, veneers, or crowns if the tooth does not need one. What do you mean when a tooth needs a crown or not, you may wonder? For example, if the tooth has had root canal therapy, or if it has a big existing fillings, or if it has fractured and a big piece of it has broken off, then it is considered necessary to have a crown on it. If the tooth is discolored and you want to have a crown on it, this is considered cosmetic, not a necessity.
It is the amount of money you have to pay in addition to your premium each year before your dental plan pays for you. This is similar to your car insurance. For example, if you have a deductible of $50 per year for your dental plan, and assuming that your insurance will cover 100% of your dental checkup and cleaning, and the bill you get from that appointment is $250, your insurance company will pay you only $200 for that appointment because of the $50 deductible on your plan. But if you have to go back to your dentist for a filling within that same year, your insurance will pay whatever is covered without deducting $50 again. In other words, deductible in your dental plan will only apply once a year.
It is the maximum amount of money your insurance will pay for your dental treatment each year. Most insurance will count the year according to the calendar year. In other words, if your plan says maximum of $1500 per calendar year, what it means is it will pay up to $1500 for your dental treatment from January 1 to December 31 of each year. Whether you have used $1500 this year for your dental treatments or you used $0, by January 1st of next year, you will have $1500 maximum coverage all over again for the new year. In other words, what have left unused last year will not be carried over to the new year. Sometimes, your insurance can start in any other month other than January 1. For example, some dental plans for university students often start from September 1st of the year and end by August 31 of the following year. So check with your insurance booklet to make sure.
Your dental plan normally covers at a different percentage for major and basic treatments. Typically, your plan covers 100% of basic treatments and 50% of major treatments. Basic treatments include all kinds of dental examinations, hygiene sessions (scaling and polishing), topical fluoride treatment (which is normally limited once a year), dental x-rays, fillings (check to see if your plan covers white composite fillings, most plans do nowadays), root canal therapy, oral surgery such as wisdom tooth extractions, gum therapy such as periodontal surgeries. Major treatments include crowns, bridges, and partial and complete dentures. In brief, basic treatments include everything except crowns and bridges and dentures.
When you are first presented to a dentist, he/she has to do a thorough dental and oral examination on you and document detailed information in the file. This is called a new patient exam. Once you become a regular patient of the clinic, your dentist will do a monitoring exam about once a year; this is called a recall exam. New patient exam is normally more time-consuming and more expensive than recall exam, and insurance will normally only cover for you to have a new patient exam once every two to five years, while recall exam is allowed normally 6 month to every year. Another exam is emergency exam. Normally emergency exam is covered unlimited number of time by your insurance plan. However, if you have emergency exams more than 2 times a year, it is probably you have not had a thorough exam by your dentist or you have not followed your dentist’s recommendation for treatment. Don’t wait for emergency to come before you visit your dentist!
Topical fluoride application is normally limited to once a year (do you remember that after polishing your teeth, the hygienist put some foamy stuff with some fruity favor into your mouth for about 1 minute and asked you to spit out the excess and advised you not to drink or eat for 30 minutes after that? This is the fluoride treatment for strengthening your teeth to prevent cavity).
Most insurance plans will allow you to have a full mouth series dental x-ray taken once every 5 years. This full mouth series basically contain about 16 to 20 small sized x-rays (about the size of a big stamp) so that each tooth in your mouth can be clearly examined on the x-ray films. This is the most informative and is of very high diagnostic values of cavity, periodontal diseases, and pulpal pathologies (root canal problems). These three categories of problems comprise 80- 90% of all oral and dental problems in the general public. Therefore, when your dentist performs a new patient examination (first time seeing you), he/she may prescribe this one as a baseline in order to develop a comprehensive treatment plan for you. This is especially important for patients with long time neglect of their oral health that require extensive dental treatments or with many existing dental restorations in their mouth.
For a patient with minimal existing fillings, minimal obvious cavities in the mouth and no obvious periodontal problems after clinical examination by the dentist, it is not likely that a full mouth series of x-rays is that valuable and justified. In this case, four checkup x-rays (also called bitewings which are only part of the full mouth series) are appropriate to check if there are any cavities developing in the posterior teeth, which cannot be detected by clinical examination. In addition, a few other small sized x-rays called periapical x-rays may be needed if the dentist believes some particular teeth are having problems but cannot confirm them with clinical examination. While full mouth series is commonly limited to once every 5 years by insurance coverage (which is quite reasonable as I don’t see why would anyone needs it more frequently than this), a few bitewings and periapical x-rays are covered every year.
Another x-ray frequently prescribed by dentists is panoramic x-ray. It is a big film showing all your teeth, jaws and jaw joints, and sinuses. Remember that you ever stood in front of a big machine with your hands holding the handles and you noticed part of the machine turned around your head while you were taking the x-ray? This panoramic x-ray is also often limited to once every 5 years by your insurance coverage. It covers a broad area in one film but gives the dentist less detailed information. It is especially poor to detect cavities, periodontal diseases, or pulpal pathologies unless they have developed to a very obvious extent. As I mentioned earlier, these three problems are the most common ones affecting the general public population. Instead of detecting common pathologies in your mouth, panoramic x-ray detects occult diseases such as a cyst or a tumor in the jawbone, an impacted tooth or impacted wisdom teeth, problems with the temporal-mandibular joints (jaw joints) etc. Because x-rays are important records of your past and present oral condition, when you decide to switch from one dental office to another one, make sure you called your previous dental office to transfer your x-rays to the new office. This will save you a lot of money, time, and exposure risk of taking unnecessary dental x-rays.
Your insurance may only cover you to have a recall exam once a year, but don’t get confused with your cleaning frequency. Most insurance plan allows you to have to 8 units of scaling and 1 or 2 units of polishing. Teeth cleaning comprises both scaling and polishing your teeth. Each unit of scaling or polishing is 15 minutes duration. Therefore let’s say you visit your dentist once a year for a hygiene appointment or a recall appointment, you will receive your recall exam by your dentist and then a cleaning as well. How many units of scaling and polishing you have received during that recall appointment? Chances are you received 3 units of scaling and 1 unit of polishing. But many people think they cannot have the insurance to cover for a cleaning again until next year. This is wrong. You can come back this year for a cleaning again (at least for scaling) depending on what is stated in your dental insurance booklet. If the insurance booklet says 6 units of scaling are limited per year and each cleaning session you have received is only 3 units of scaling, then you can have at least 2 times of cleaning session per year covered by your insurance. Just make sure you do not receive recall exam again at your subsequent cleaning sessions. Most people with reasonable oral hygiene habits and do not have periodontal problems should be enough to have once a year cleaning session. Some people, however, do need cleaning every 3 months or every 6 months if they develop plaque and calculus easily and/or they are at high risk of developing periodontal(gum) disease.
This term means that your dental office will send the claim form for you to your dental insurance company, which will pay the dental office directly. You only have to pay the co-payment portions you are responsible for the treatment you have received. This is an extra service that some dental offices offer to their patients.
For expensive dental treatment plans, such as crowns, bridges, and dentures, most insurance companies encourage patients to send a predetermination, outlining what dental treatments he/she is going to receive and how much it will cost, before going ahead with the treatment. Personally, I think this is prudent for the patients to do so. The advantage of this predetermination/preauthorization procedure is as follows:
On the other hand, if you understand that the treatment plan is really good for you, you should go for it even though your dental insurance does not approve for it. After all, your oral health is an important part of your overall well-being. This is what I mean, “not to become insurance dependent.” Another situation that predetermination or preauthorization may not be applicable is that when you know you are going to receive the treatment whether the insurance will cover it or not. For example, I had an emergency patient, who presented with a front tooth fractured almost down to the gum level. The tooth has had root canal therapy. The patient is very concerned about appearance and esthetics. She cannot accept walking out the clinic without having the tooth restored to its original beauty. After thorough consideration, I proposed that the tooth would be best restored with a post-core and all ceramic crown. I presented the estimates of costs to her and she consented to me to start immediately. She left our clinic with a provisional crown on that day, and received the final crown 4 days later. At that time, she was very happy with the service even though she still did not know if the insurance would cover the crown or not. In this emergency situation, predetermination is not appropriate, as she knew she would go for it whether insurance would cover or not.
If you want to benefit from the good quality treatment available nowadays, you have to change your attitudes and values towards dental and oral health. I have noticed many people do not have good dental treatments not because they cannot afford them but because they do not value them. I have come across with many people, who would spend $100 for a meal or $200 for a pair of jeans, but think it is too expensive to have dental cleaning once a year! So often, I noticed some people in shopping malls, dressed themselves in expensive outfits and with fancy hairstyles, but I can easily see discolored teeth and poor dental restorations when they smile! If you do not see how a beautiful smile with healthy teeth affects your confidence and image, you will not spend for it even you can afford it. So next time, when you think of visiting a dentist is very expensive or having a new crown is very expensive, think about how important your oral health and your appearance is. Maybe you will begin to appreciate the values of spending for it.