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Dental Insurance Questions and Answers

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Dental care is expensive, and most dental insurance plans cover just a portion of the cost of care. To get the most from your dental plan policy, there are a few things you need to know before you receive dental services.


Below is a list of 15 common dental insurance questions and answers. They were developed with the help of a Washington, DC-based dental practice. Dentists and their billing administrators work closely with dental insurers to get claims paid. They are uniquely positioned to know what insurance coverage is needed, what insurers pay for claims, and which claims they often deny.

                        
Dr. Bridgette Rhodes, DDS

Click the tabs on the left side of the page to view the dental insurance questions and answers.

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You may need dental insurance if you answer "yes" to two (2) or more of the questions below.
  1. Was your last dental cleaning more than 18 months ago?
  2. Do you have broken or missing teeth?
  3. Do you have bleeding or painful gums?

Other things to consider when deciding if you need dental insurance.

If your employer pays part of your dental insurance premium, you and your covered family members may receive more benefits than you contribute in premiums (if any).

If you are responsible for paying 100% of the dental insurance premium, determine if what you pay in premiums will be greater than what you expect to receive from the plan. Remember that if you are participating in an employer-sponsored plan, you are probably paying premiums with tax-free dollars, reducing dental insurance costs even more (see Example).

For example, suppose your annual dental insurance premium is $480 ($40/mo.), and you anticipate receiving two regular dental cleanings at $150 each ($300 per year). In that case, it may seem like you would save $180 if you paid for the cleanings out of pocket instead of purchasing insurance. However, if your dental insurance premium is tax-free, the $480 per year is closer to $336 (assuming a 30% tax savings). For an additional $36, you can have insurance coverage for the remainder of the year to cover unplanned dental care expenses.

You can maintain this coverage for as long as necessary and terminate the coverage when needed
and allowed by the plan. Work with your dentist to create a treatment plan for your dental care needs.

The final question you need to answer is:

Can you afford to cover expected or unexpected dental care expenses ranging from a few hundred to a few thousand dollars without insurance?

Affordable Care Act (aka Obamacare). As of January 1, 2014, plans on the Exchanges have to provide child dental coverage as part of a medical or stand-alone dental plan. Adult dental coverage is not required but may be purchased on the federal and some state Exchanges.

  1. Comprehensive Oral Exam: typically performed on patients visiting a new dentist. It falls under the preventive and diagnostic services category and is usually paid at 100%. The dentist takes diagnostic X-rays and checks for cavities and other abnormalities. If the patient had x-rays taken within the previous 12 months, they could request their former dentist forward the x-rays to the new dentist.

  2. Periodic (Routine) Oral Exam: typically performed every six months or twice yearly when the patient visits the dentist for routine cleaning. It falls under the preventive and diagnostic services category and is usually paid at 100%. The insurer may not cover additional exams/cleanings beyond the two

  3. Limited (Problem Focused/Emergency) Exam: typically performed on patients with a specific oral problem or dental emergencies, such as an infection or pain. It may require diagnostic procedures such as X-rays. The exam and x-rays fall under the preventive and diagnostic services category and are usually paid 100%. Suppose emergency treatment is required at the time of evaluation. In that case, these services usually fall under the basic or restorative services categories and are usually subject to a deductible and coinsurance (%) amount. Review your plan documents to see if limited exams are covered separately or in place of routine exams

Dual coverage is not the same as double benefits, and it does not mean that combining both plans' benefits would cover 100% of the cost of a particular dental procedure. For example, if your primary dental plan pays 50% of the cost of a crown (up to a maximum dollar amount), and your secondary plan pays 60% for a crown, you would likely receive a total benefit of 60% and would be responsible for the balance. This is because most plans have non-duplication rules that state that they will only pay the difference between what the primary carrier paid and what the secondary carrier would have paid if they were primary.

Consequently, enrolling in more than one dental plan makes sense if:
  • one plan provides benefits you need that are not provided by the other plan
  • one plan provides a greater reimbursement for dental services that you plan to use, and the percentage difference is greater than the cost of the premium of the second plan
  • enrollment is free


THIS TOOL DOES NOT PROVIDE INSURANCE ADVICE. It is for general informational purposes and does not address individual circumstances.