UNDERSTANDING PPO DENTAL INSURANCE
Many patients with dental insurance feel they are well covered when they visit the dentist. They are quite surprised when they find out they have to pay more than expected or for the entire treatment even with their insurance coverage. Most patients are well informed through their company on the basics covered, cleanings, x-rays, fillings, etc. Since it is ultimately the patient's responsibility to pay the final balance, it's a good idea to know the underlying details behind insurance coverage in most cases.
DENTAL INSURANCE HIGHLIGHTS
• YEARLY MAXIMUM - This the total amount your insurance company will issue in checks to your provider during a 12 month period, if you have a $1500 maximum it doesn't mean you can go out and get two treatments for $750 each. Your insurance covers a percentage of each treatment; they will continue to pay on approved treatments until they reach the maximum within the time allowed. The benefit year doesn't always run from December to January, you should be aware of when your coverage year ends in order to coordinate your treatments in a timely manner and not lose any of your yearly benefits. Remember, if you don't use your maximum, you lose it. Some plans allow a separate maximum for orthodontic treatments.
• DEDUCTIBLE - this is a yearly fee paid by you and must be met before your insurance starts paying your treatment claims. The dental office generally collects this during your visit. Understand what your individual and family deductible is. If you're a family of 3 and your family deductible is $150, each family member will pay $50, until the $150 is met. Most plans do not require you to pay this deductible during your initial diagnostic and preventative visit (routine cleaning, x-rays, exams), but when you have an actual treatment performed.
• FREQUENCY LIMITATIONS - this is the number of times you can have a certain procedure performed during your coverage year. Many plans allow 2 cleanings a year. You must really understand whether you can have 2 cleanings "anytime" during the year or exactly 6 months apart. If for any reason you were to go to a dentist and in less than 6 months go to a different dentist and have a cleaning done. You will get the statement in the mail to pay for a visit.
• CO-PAY - This is a confusing subject for most patients; they often confuse co-pay with deductible. Co-Pay is the percentage of the treatment you share in paying with your dental plan, if something costs $100 and your plan covers 80%, you pay $20 and they pay $80. It is essential that you find a dental office that not only accepts but also is contracted with your insurance company. A contracted dentist agrees to accept the plan's discounted fee schedule, which translates to savings for you. By visiting a contracted dentist, your yearly maximum covers more treatments. A non-contracted dentist usually gets paid based on his usual and customary fees (UCR).
• FILLINGS - Many plans will not pay for all composite fillings, they downgrade any fillings done on posterior (back) teeth to Amalgam (black/metal) fillings. If your insurance plan covers 80% of fillings, your co-pay is 20% of the Amalgam fee and you are also responsible for the difference in fees between the two types of fillings. Generally, an insurance company will pay for a filling on the same tooth every two years. Obviously, this doesn't apply if you switch insurance companies.
• CROWNS PRIOR PLACEMENT - Many plans have what they call "prior placement", this means that if your crown is to replace an existing crown, they want to know when the existing crown was placed in your mouth. The insurance company will not pay for a replacement crown if the existing one is less than 5 years old. If the original crown was done at a different dental office, the doctor will rely on your statement of when you think it was originally done and notify the insurance company. Many plans will only pay for a certain type of crown (metal, porcelain over metal). If you want a cosmetic rated product, such as full ceramic and Zirconia crowns, you will be responsible for your co-pay plus the difference in the product fee.
• BRIDGE MISSING TOOTH CLAUSE - Let's say years ago you had a tooth extracted and you left that spot open because you couldn't afford a bridge or implant. Now you have dental insurance, you're excited and you go to see your dentist, you're finally going to have a bridge placed to fill that gap right?, well, I hate to burst your bubble but if your insurance plan has a missing tooth clause, it means that if the tooth was not extracted in the last 6 months, they will not authorize your claim for a bridge and you will be responsible for the entire treatment.
• WAITING PERIOD - Many insurance plans have a waiting period on major services, the amount of times varies, but what this means is for a period of time, your insurance will only pay for diagnostic, preventative and basic services (x-ray, cleaning, exam, fillings). You can only use your insurance for major services (crown, bridge, etc.) after you've had the plan for a period of time. You need to be aware of this.
• EOB - Explanation of Benefits. Please check your mail for the statements from your insurance company. Call your insurance company with any questions regarding payments made. Remember that patients are responsible for any unpaid balance from the insurance company.
We can't say your plan will have all these limitations, but can almost guarantee it will have one or more of these. A well-informed patient is empowered to make the right decisions. Here's a quick matrix to help you quickly view everything mentioned:
|YEARLY MAXIMUM||The amount your insurance will pay for a plan year ||How much is the yearly maximum? And when does my plan year start and end? Do I have a separate maximum for orthodontic treatments?|
|DEDUCTIBLE||The amount you're responsible to pay once a year|| Do I have an individual/family deductible and how much? Does my deductible apply to diagnostic and preventative?|
|FREQUENCIES|| How often you can have routine visits|
How often am I allowed cleanings? If twice am I allowed anytime or exactly every 6 months?
|CO-PAY||The percent your insurance covers for a group of service||What is the percent covered for each service group?|
|FILLINGS||Amalgam or Composite||Are fillings downgraded on posterior teeth?|
|CROWNS||Also known as a "cap"||Does my plan have a prior placement stipulation?|
| BRIDGE||A minimum of 3 crowns, 2 serving as anchor for the one in the middle covering the area of a missing tooth||Does my plan have a "missing tooth clause"|
A period of time you must wait before your insurance will pay for certain services
|Does my plan have a waiting period? If yes, how long? And for what?|
WHAT CAN THE DENTAL OFFICE DO FOR YOU?
We at Huntington Smiles will request a complete breakdown of your coverage during your first visit, don't hesitate to ask for a copy of the breakdown, you can also request this directly from your insurance company. At our office we will take the time to explain your coverage in detail to you and answer any questions you may have.
(We are conveniently located where Alhambra, South Pasadena, and San Marino meet, the white building right across from In-N-Out and Twohey's)
Monday 9:00am - 5:30pm
Tuesday 9:00am - 5:30pm
Wednesday 9:00am - 5:30pm
Thursday 9:00am - 5:30pm
Friday 9 :00am - 5:30pm
Saturday 9:00am - 4:30pm
Michael Su D.M.D.
100 E HUNTINGTON DRIVE, SUITE 206, ALHAMBRA CA 91801 TEL: (626) 308-7881