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Dental Insurance: Is It Really Insurance?

If you find dental insurance confusing, you are not alone!  Not only is it a subject that continually changes, the name itself is misleading.  Is it really an “insurance” at all?

What Dental Insurance is Not

The reason we think the name “dental insurance” may be a little misleading is because it brings to mind other types of insurance, like car insurance or medical insurance.  With most types of insurance, you pay some type of premium (monthly or annual), you have a deductible to meet, and then you receive almost unlimited benefits.  Your homeowners’ insurance covers the total value of your house.  Your medical insurance may have a maximum amount of benefits, but that maximum is typically far above what most health concerns would use.

For example, last year Hurricane Harvey destroyed many homes in Houston.  If you had coverage for flood damage, you paid your $10,000 (or whatever amount) deductible, and then your homeowners’ insurance paid for the remainder of the repairs necessary.

Or let’s say you break your leg and need orthopedic surgery.  If you have medical insurance, you will pay your $5,000 (or whatever amount) deductible in the emergency room.  Then your $55,000 orthopedic surgery is covered fully.

Unfortunately, these are examples of what dental insurance is NOT.  Wouldn’t it be wonderful if you paid a certain amount for a deductible and then you could fix every problem in your mouth that year?  That is just not how dental insurance works

What Dental Insurance Is

The easiest way to describe dental insurance is to call it a discount plan.  When you have dental insurance, typically through an employer, that insurance carrier pays a portion of the fees accrued at the dentist.  Very few plans require a deductible, and if they do, it is usually as low as $50-100.  Dental insurance carriers specify how much they will pay for each specific dental procedure, and you (the patient) are responsible for anything over that amount.

So in order to properly understand dental insurance, it is best to think of it as a discount plan that lowers the amount you pay for certain procedures.

What Are the Different Kinds of Dental Insurance?

To make matters even more confusing, there are many different kinds of dental insurance providing different types and amounts of benefits.  In general, we can break these down into three categories:

  1. PPO – This is the type of dental insurance that allows you to choose which dentist to see for your care. PPO stands for Preferred Provider Organization.  This means that certain dental offices are “preferred providers” for a specific dental insurance carrier.  A PPO type of insurance can be further broken down into two types of coverage:
    1. In-Network Provider – An in-network provider is a dentist who has signed a contract with the dental insurance carrier, agreeing to charge specific dollar amounts for specific dental procedures. There are certain limitations placed on in-network providers that could affect the quality of your dental care.
    2. Out-of-Network Provider – An out-of-network provider is a dentist who accepts and files your PPO dental insurance without signing a contract with the insurance carrier. This means the dentist has the freedom to treat each patient as his or her dental needs require, with no restrictions from the insurance company.  It also means that the insurance carrier can elect not to pay for certain procedures or pay a much smaller amount than they pay to an in-network provider.  This is  a growing trend among insurance providers: to pay very low amounts to out-of-network providers, thus encouraging their customers to only see in-network providers.
  2. DMO – Similar to an HMO type of health insurance, a DMO insurance plan does NOT allow you to choose who you see for dental care. Patients are assigned to certain dental offices based on numbers alone, with no regard to your specific needs or desires.

How Can You Understand Your Specific Benefits

There are some important things you should know about your dental insurance.

First, you should know whether you have a PPO or a DMO plan.  As stated above, a DMO requires you to see an assigned dentist.  You cannot choose your own in order to receive benefits.

Next, you should know what your yearly maximum benefit amount is.  The average maximum currently is $1500-2500 per year.  Knowing this amount can help you plan the timing of certain treatments.

You should also know that most dental insurance companies will not pay for procedures categorized as “cosmetic dentistry”.  This includes teeth whitening and veneers.

Another important fact is that Invisalign does not fall under the category of “cosmetic dentistry”.  It is an orthodontic procedure and does qualify for dental insurance benefits if you have orthodontic coverage.  Many people do have adult orthodontic benefits, which pays up to $3000 of their Invisalign treatment!

More Questions about Dental Insurance?

For once, we won’t tell you to call to schedule a consultation with Dr. Ann and Dr. Lauren, because they are not the experts in dental insurance.  They are the experts in dentistry.  It is actually a good thing that they are not encumbered by dental insurance knowledge.  This allows them to assess your dental needs and formulate treatment options based on what is best for you, not based on what your dental insurance decrees.

You can, however, call and speak with Johnita, our office manager.  She has decades of experience in dealing with various dental insurance carriers and financing options.  She understands all of the minute details therein, and she can help you understand your specific plan.