Dental Insurance Works
how dental insurance works in a language you can understand. No legal-ese here.
You either buy your own dental insurance or your employer provides it, usually
at a reduced cost to you. You or your employer buy a certain level of coverage,
be it 80/20 (80% of "reasonable and customary charges paid by your
dental insurance, the other 20% paid by you) or 90/10, or 50/50, etc. They all
work the same with different payout levels.
here's how reasonable and customary charges are compiled. The dental
insurance companies may survey 10 or more dentists in your area for what their
current charges are, by procedure. Out of these surveys, an average will be reached.
That average is considered the"reasonable and customary" charge for
your area. (Note: I dont think there is a set time for how often "reasonable
and customary"charges are updated, so buyer beware! You know prices can go
up without notice).
you or your employer goes to buy dental insurance, the insurance company will
have several plans to choose from. The best, most costly plans will pay for 100%
of reasonable and customary charges, next is 90/10 and 80/20 plans (80% paid by
insurance, 20% paid by you, etc.) So far, so good.
lower cost plans may pay only 80% of the reasonable and customary charges (again,
it may be 80% paid by insurance, 20% paid by you, but the amounts paid by insurance
will be lower because its only paying 80% of the reasonable and customary
insurance company will have plans for 70/30, 60/40, and so on, with the lower
the coverage, the lower the cost.
or your employer decides your level of coverage.
can be confusing, so here's an example. Lets say, reasonable and customary
(R/C) amount for a procedure is $100.
A pays 100% R/C, and is split 80/20.
Insurance A pays $80, you pay $20
B pays 80% R/C , and is split 80/20 (80% of $100=$80)
Insurance B pays $64
(80% of $80) and you pay $36 ($100 - $64)
dental insurance plans offer payments by "fee schedule," setting a flat
fee per procedure and paying a certain % of the fee regardless of what the actual
R/C is. They may still call it their reasonable and customary charges, however.
some quick FAQ's:
dental insurance has a deductible. How does that work?
lets say your insurance has a $100 deductible. Deductibles apply once every
year, be it calendar year or business year. Some businesses have a business year
that begins in, say, June, and ends May 31st of the following year. For this example
we will assume your insurance goes by calendar year, January to December.
you go to the doctor in January for a covered procedure, and the charge is $100,
and your insurance pays 100% R/C on a 80/20 split. If your deductible was met,
the insurance would have paid $80.
since your deductible has not been met, $80 of your doctors visit will go
toward your deductible and not be paid to anyone. Most patients do not realize
that the amounts that go toward the deductible are only what insurance would have
paid, not the whole charge.
What is a provider for dental insurance and is my dentist one?
companies try to sign up doctors as "providers" for them, as a way to
entice patients to their practice. Upon agreeing to be a provider, the doctor
agrees to accept only the insurance payment and writes off what the patient would
normally have to pay.
course, the more the insurance company will pay, the bigger incentive for the
doctor to sign up. Or they may consider the largest industry in the area, and
sign up with their insurance carrier to get a steady stream of patients. You can
bet, if your doctor is signed up as a provider for a large number of insurance
companies, an appointment will be harder to get. Most, however, will sign up for
your state or citys plans and only the most popular. Keep in mind it is
an incentive to get patients. Some practices may already have more patients than
appointments and have no need to be a provider for insurance.
your dentist charge more than average?
can conduct your own survey and find out. Call around and ask what a typical office
visit will cost (or choose any procedure you want) from several different dentists,
then compute your average. Be sure to compare apples to apples, though. If your
dentist is a specialist, compare with only other specialists in the same field.
if I dont have dental insurance?
are plans you can buy that provide coverage for most dental procedures. These
plans are usually reimbursement plans where you pay for the service and submit
receipts to them yourself. Some are expensive, some are reasonable.
conclusion, you really need to shop around.
note: This last bit of excellent info comes from Jeanne from Tennessee:
My husband is a
dentist and I have worked in his practice for 16 years. The bottom line (in my
opinion) on dental insurance is that is not to bother with it unless it is offered
by your employer as a "free" benefit. The problems with dental insurance
are as follows: 1. The maximum annual allowance is usually $1500-- this has not
changed since 1976. 2. They dictate treatment. For example, many plans won't pay
for a patient to have a tooth colored (composite) filling--they WILL pay for a
mercury-filled ugly amalgam filling. 3. The premiums (if you don't have a group
plan) are usually almost as much as the annual maximum. You are better off to
pay as you go and find a dentist that you can trust that does quality dentistry.
Most dentists who participate in all the "plans" are high volume practices
and quality may not be their first concern since their fees are greatly reduced
by the insurance company. Therefore, they have to see more patients. 4. Insurance
companies do everything possible to keep from paying anything. They delay payments
and "loose" claims frequently. We spend a great deal of time chasing
down insurance claims and payments.
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