How Can I Make the Most of My Dental Benefits?


One of the most confusing aspects of dental benefits is that each plan is different. So when a patient asks “Will my dental insurance pay for this?”  the answer, “It depends,” is not very helpful. The reality is that every insurance provider offers distinct benefits and the details can be confusing. It pays to learn as much about your plan as you can.

Here are some of the basic terms and guidelines that are common to most plans:

Cost-sharing

Most medical plans do not include coverage for dental services. Usually, dental services are covered by a separate plan. Dental insurance is designed to pay a portion of the costs associated with dental care. The dental benefits offered are not intended to cover the entire cost of your dental care. Most dental plans include cost-sharing elements aimed at controlling costs. Certain out-of-pocket costs like co-insurance, co-payments, and deductibles must be paid by the patient.

Class-of-service

Dental insurance plans characterize the type of dental care you receive into a “class of service.” Typically there are three classes of service that are reimbursed at different rates:

  • Class I procedures are diagnostic and preventive – such as exams and cleanings.  These are usually covered at the highest percentage (for example 80 percent to 100 percent of the plan’s maximum plan allowance).
  • Class II procedures are basic or necessary – such as fillings, extractions, and periodontal treatment. These may be reimbursed at a lower percentage (for example, 70 percent to 100 percent).
  • Class III is for major restorative care – such as crowns, bridges, and dentures. These are most often covered at 50% and may be subject to a waiting period.

Note: Some plans offer a separate class for orthodontic procedures.

Coverage limits

Dental plans set an annual limit on the number of dollars that are spent on your dental care. Also, there is usually a separate lifetime maximum that applies to certain procedures.

Services may have frequency limits, such as the number of exams and cleanings a year, or how often crowns can be replaced.

Dental plans do not cover every dental service that may be suggested by your dentist. For example, implants and cosmetic services such as teeth whitening are rarely included as a dental benefit.

Preferred Networks

Dental plans are similar to medical plans, with a network of contracted providers that offer discounted services based on rates negotiated by the plan. Your ability to choose your dentist and the amount of your out-of-pocket costs will depend on the type of plan you have.

  • DHMO. Dental health maintenance organizations restrict coverage to dental professionals within a limited network.
  • DPPO. Dental preferred provider organizations are similar to DHMOs but do cover services provided by dentists outside the “preferred” network.
  • Dental Indemnity Plan.  A dental indemnity plan allows you to choose any dentist you want, and you can see a specialist without a referral.

Choosing a dental plan can be a daunting task. Not all dental providers participate in network contracts. Talk to your dentist and research the available plans before you decide. Every dental plan must provide in a written document the details of its service coverage, requirements, limitations, and exclusions. You can often access these documents on the insurer’s website.

Remember, healthy teeth make a healthy smile!

Dr. Nishan Halim

Note:  Although we do not contractually participate with dental insurance companies, we do work closely with all PPO dental benefits companies. We are happy to file a patient’s dental benefit claim on their behalf.


Nishan Halim, DMD specializes in adult and pediatric restorative and cosmetic dentistry, as well as preventive dentistry in his Capitol Hill, Washington DC neighborhood dental center. Contact Dr. Halim to schedule an appointment to discuss and clarify your insurance options. 

 

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