Understanding Dental Insurance

Do you understand how your dental insurance coverage works? In this article we will explain the important concepts and common questions many patients have about dental insurance. According to the 2017 NADP Dental Benefits Report, two-thirds of Americans have private dental coverage. December is usually a very busy time for many dentist offices because many patients want to use their benefits before the benefit period ends.

Is Dental Insurance Truly “Insurance”?

Most dental insurance plans are not like auto or home insurance plans in the sense that they do not cover you for catastrophic and undesired occurrences. Take auto insurance for example, it will kick in only when you have accidents that have a low chance of happening. Auto insurance does not cover your car for a 6-month check-up so to speak, unlike dental insurance. Basically, most dental insurance plans are defined benefit plans with limitations. The limitations are there to contain their cost. As a patient, it is very important to know your plan’s limitations. Oftentimes the limitations are buried under small prints.

Key Concepts and Terms

Frequency limitations: Each plan has frequency limitations such as two cleanings per plan year. It is important to know what “plan year” means for your plan and if there are other fine lines. Most plans have a calendar year as their “plan year” while other plans have Mar. 1, June 1, Oct. 1, or Dec. 25 as the plan year’s start day.

Annual deductible: This is what the patient has to pay BEFORE your plan starts to pay the defined proportion of coverage. It renews every plan year. For many preventive services such as exam, cleaning, or x-ray images, the deductible is waived. You pay your deductible to your dentist but the deductible is charged by your dental plan not by your dentist.

Annual maximum: Each plan has predefined annual maximum. The plan will not pay anymore (penny more 🙂 ) when the total accumulated payment exceeds the annual maximum. Remember this is the TOTAL payment your plan has paid so far. It starts to pay again only after the new plan year starts.

Pre-authorization/pre-determination: Before you receive more extensive dental treatments such as deep cleaning, crown and bridges, dentures, and implants, your benefit plan wants to authorize it. Your dentist’s office sends all the necessary documents to the plan administrator (Aetna, Cigna, Delta Dental…) and they review it then send their statement explaining in detail how much they would “likely” pay. This is the best assurance the dentist and the patient can receive BEFORE the desired treatment. Unfortunately, there are NO GUARANTEES. The benefit plan can decide not to pay after the treatment is rendered based on the circumstances at the time of reviewing the claim.

This process typically takes 2-3 weeks and could be longer if the treatment is more extensive. Your benefit administrator is typically a huge company working on your case and it is hard to keep track of the progress. So please do not wait until the end of December to use your dental plan and FSA to receive big treatments.

Your patient payment portion: Your patient payment portion depends on many different factors as exemplified above. You would pay your estimated patient portion on the day of service but it may need to be adjusted based on what your dental plan decides on the proportion of payment.

We Are Here to Help

We are here to help you navigate the complicated world of dental insurance. Please communicate with your dentist’s office and  work with them to get personalized guidance and use your plan to its best.


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