Fall is the time of year we think about school, football, holidays and…dental insurance. Dental insurance? It may be wishful thinking on my part, but anyone fortunate enough to have dental insurance really needs to think about it every fall!
You see, most insurance plans have calendar year maximums that renew every January 1st. For people needing even modest amounts of treatment, one year’s maximum often will not cover most of their treatment. By doing some late this year and some early next, you will receive twice the benefit. Beware waiting till December to see your dentist, though. The later in the year you wait, the less likely your dentist is to be able to get you in. There are often many other last minute requests for treatment. Now for some commonly asked questions…
Won’t my plan yearly maximum cover a lot of treatment? No, most plans cover a maximum of $1000 to $1500. Guess how much insurance plans covered 30 years ago…
$1000 to $1500. It doesn’t go nearly as far as it did 30 years ago. If plans had kept up with the true cost of dental treatment, they would be covering at least $3000 per year.
Will my insurance cover all my expenses up to the maximum? No, while many plans do pay most or all of diagnostic and preventative charges (exams, x-rays, and routine cleanings), other procedures are covered at percentages of U.C.R.
What is U.C.R.? Usual, Customary, and Reasonable is what it stands for, but it is a bit of a misnomer. Each insurance company seems to have its own U.C.R. numbers for what each procedure should cost. These numbers are almost always lower than a true average of dental offices in a region. It would appear that these are arbitrary numbers that each company claims is the usual.
Are some procedures reimbursed better than others? Yes, most plans do diagnosis and prevention at near 100% of UCR. Routine fillings and extractions are usually at 80% of UCR. Crowns (caps), dentures, partials, surgery, and root canals usually are only covered at 50% of UCR. Dental implants, the best way to replace teeth, are usually not covered at all.
Are some insurance plans better than others? Yes, the plans vary according to how much the employer or patient pay for them. Network, or PPO, plans tend to cost the employer less, but there is a penalty for seeing “out of network” dentists. Better plans let patients see the dentist of their choice and have higher calendar year maximums ($2500 is the best I’ve seen).
What if I elect to go out of my PPO plan’s network? Your co-pay (the amount you are responsible for) will be higher, but you may find it worthwhile to see the dentist of your choice. So here’s my advice to use your insurance wisely. Use it every year for diagnostic and preventative care. Then if there are problems found, they will likely be small and fixable with routine and well reimbursed procedures. I always tell my patients that dental insurance is great for keeping you out of serious dental trouble. Once serious trouble has developed, most plans won’t go farto fix them.