Here at the office we often get patients that are not fully educated about their dental insurance benefits. This leads to a surprise when they find that their much needed crown is not covered at the estimated amount. Fortunately, dental coverage is not as tangled in rules and regulation as your medical coverage is. That being said though, there are a few big points to remember when knowing what your insurance provider will cover and what they wont.
Frequencies and Limitations
Most dental insurance providers have clauses that pertain to frequencies and limitations regarding what is and is not covered. Frequencies are implemented to reduce your insurance company’s obligation to cover multiple procedures of the same type in a given period of time. For example, your insurance provider will cover 50% of a PFM crown for tooth # 3 every seven years. If you got a crown on tooth # 3 in 2013 and you now need another one in 2017 because you broke it, your insurance company will likely not cover that procedure. It fails to meet the 7 year frequency requirement. Another example is only having 100% coverage on two hygiene appointments every 6 months. (Its actually 6 months and 1 day.)
Limitations generally refer to the nature of your needed procedure rather than the time frame. Insurance companies often limit reimbursement up to a certain amount based on the type of crown, bridge or filling that is done. For example, your coverage provider might deny coverage for a 3 surface composite filling but they would have covered a 2 surface.
Downgrading is another tool used by insurance providers to limit their coverage obligation. This can sometimes lead to the patient receiving a bill for services that they had not anticipated. Lets review a hypothetical example.
Ms. Smith comes in for a composite filling. Dr. James performs the procedure and all is well. Ms. Smith pays her out of pocket portion and the 80% remaining balance is filed with her insurance by the dental office. Three weeks later Ms. Smith receives a bill from Dr. James stating that she owes a portion of the 80% that was filed on insurance. She calls Dr. James’s office and asks why she is responsible for more of the balance when she was told otherwise. Her insurance company “downgraded” the procedure to a less expensive amalgam filling and covered 80% of that amount. The problem lies in that an amalgam filling was not what Dr. James actually did. He performed a more expensive composite filling because it was an anterior tooth and Ms. Smith wanted to retain the natural look that composite material allows for.
Yearly maximum refers to the total amount of money that your insurance company will allocate to dental treatment in a given year. Sounds fairly simple but there are a couple things to remember.
The first is that the an insurance company’s definition of “one year” varies from plan to plan . Some plans define a year as a “calendar year.” This means your coverage amount starts January 1 and ends on December 31st. Other plans define a year as 365 days from the date that your coverage went in to effect. If your coverage began on May 10th, it will renew on May 10th or in some cases May 11th of the following year. It is important to know how your coverage defines annual or year and how it will financially effect your treatment.
Secondly, maximums have not risen well with inflation in decades, though premiums have. Most dental plans allow for $1000 in total coverage every year. Unfortunately the cost of materials and labor for dental treatment has gone way up. A more reasonable maximum to better cover dental procedures would be over 5x this number.
To bring this all together, its important for patients to understand the ins and outs of their dental coverage plans and also know that these clauses can conflict with what treatment is best. Your dentist is trained to provide you with the best care that corresponds to your individual needs. Your insurance provider is not in the operatory with you and in order to remain profitable, must lump coverage in to broad terms that don’t always have your best interest in mind. Take the time to meet with your dental office’s insurance coordinator but also understand that it is impossible for them to know every clause. From state to state their can be literally hundreds to thousands of plan variations.