Understanding Your Dental Insurance Policy
In-network vs Out-of-network
In-network means that your dentist has signed a contract with that particular dental insurance carrier network. For example, dentist in VA may choose to sign a contract with Delta Dental PPO, Delta Dental Premier, Guardian, etc. Each network provides the dentist with the fees that can be charged for each type of procedure. Then, from that set fee, the insurance plan will pay a portion and the patient will pay a portion.
Out-of-network means that your dentist has not signed a contract with that particular dental insurance network. For example, a dentist may sign a contract with Delta Dental Premier, but not Delta Dental PPO. This means that Delta Dental PPO patients would see that dentist as an “out-of-network” provider but Delta Dental Premier patients would see that dentist as an “in-network provider.” When a dentist is considered out-of-network, the insurance company cannot set the fees charged for each procedure. Instead, the dentist sets their fees, then the insurance plan will pay a portion of those fees and the patient will pay a portion of those fees.
Most dentists in the Roanoke Valley are only in-network with 0, 1, 2, or 3 insurance networks. Meaning, that going to an out-of-network provider is actually quite common for many people with PPO plans. Many plans such as Ameritas actually pay very well for out-of-network services. It is helpful to read the plan contract to understands the terms.
Most plans will pay pretty similarly for both in- and out-of-network care. However, some plans are very restrictive towards out-of-network care and may not pay as well.
Did you know that your dentist cannot offer any discounts, write offs or courtesy services if they are contracted with and filing dental insurance claims? Any version of a cash discount, write off, etc would be considered insurance fraud in this case, which is why dentists will often offer a discount plan instead.
How are dental fees / prices determined?
The National Dental Advisory Service completes a national survey of fees and categorizes them by zip code and percentile. Most dentists will use this survey of fees to set their prices so as to be fair to all patients.
Did you know that prices for materials, lab costs, employees, etc go up every year? Roughly 1 in 4 dentists have seen costs increase by nearly 20% in recent years. Dentistry is an extremely high overhead business to operate. Typically over 75% of money brought in by a dental practice goes to paying for costs of running the business. When you include paying the dentist a reasonable salary in that overhead, the percent increases dramatically from there. This means that fees charged must cover this dramatic overhead. Often fees set by contracted dental insurance companies don’t reflect the cost of providing the actual care, meaning dentist must see double or triple the amount of patients in the same amount of time to afford to maintain that dental insurance contract. Sometimes this can result in rushed care. Further, insurance companies haven’t significantly increased their reimbursement rates for over 20 years, leaving a large discrepancy between the cost of providing care and the amount insurance companies are willing to spend on care.
The main types of dental insurance / benefit plans are: DMOs, PPOs, Discount Plans, and Government plans like Medicaid
DMOs : These types of plans typically have lower monthly premiums, but are very restrictive. Enrollees can typically only get their insurance carrier to pay towards their care if they go to an in-network dentist. Most dentists in the Roanoke Valley are not in-network with these types of plans.
PPOs: These plans are the most common in our area. Most will pay towards dental care for both in-network dentists and out of network dentists. These types of plans can be purchased individually or m ay be supplied by an employer. Often, employers will negotiate a lower monthly premium for their employees by having restrictive clauses added to the plan, which is why it is important to read the plan clauses carefully. These plans can by fully or self-funded.
Discount Plans: These are offered by individual dental offices to give patients a discount on services in the dental office over cash prices. Dentists cannot offer discounts for cash paying patients as this would be considered discrimination and insurance fraud, so discount plans give patients without insurance a way to receive care at a reduced rate.
Government plans: Patients with plans such as Medicaid, administered by DentaQuest in VA, must receive care from contracted dentists in order for the plan to pay towards the care. If patients with the plans choose to see a non-contracted dentist, they can either choose to pay cash prices or enroll in a discount plan to receive discounted care. Medicare does not typically offer dental benefits, so seniors will often look for individual PPO plans to enroll in or sign up for dental discount plans.
Terms, Clauses, and More to Know
Annual Maximum: Most insurance plans will cap the total amount they pay towards care for the year to around $1500 or $2000. This means that any work needed beyond that cap is paid totally out of pocket by the patient. In this way, dental insurance carrier leave most of the risk on the shoulders of patients. Did you know that the cost of the “free” preventative services such as cleanings, xrays, and exams are deducted from this total each year, often leaving very limited funds for and dental treatment needed.
Least Expensive Alternative Clause: these types of clauses will only agree to pay to fix the problem per any option available that is the least expensive. For example, if a patient would like a tooth to be replaced by an implant but they COULD replace the tooth with a cheap plastic removable appliance, the insurance company will pay as if the patient is getting the cheap appliance.
Waiting period: this is a period where the insurance company will not pay for some or all dental services, often 90 days up to 1 year.
Missing Tooth Clause: If a patient was missing a tooth prior to beginning the dental insurance policy ,the insurance plan will not pay towards any replacement of that tooth.
Self-funded vs fully funded: if a plan is self-funded, the employer pays the costs of claims, while insurance companies pay the costs of claims in fully funded plans. In the case of insurance company overpayment, the patient gets to keep the overpayment for self-funded plans, whereas out-of-network dentists get to keep the overpayment in fully funded plans.
1 Service per year: this means that you can only have that service done once each year, meaning if you need several crowns, your insurance company will only pay for 1.
Not-covered: the insurance company will never pay for the service. The patient in this case would pay the amount owed based on the dentist’s fees.
Covered Service but Not-payable: the insurance company will sometimes pay for this service, but in this particular instance, perhaps due to age limitations or frequency, they won’t pay. The patient pays the full amount owed based on the contracted insurance fees.
Copays, coinsurance, deductible, and more: Most dental insurance plans will require that patient pay a certain amount of money out of pocket before covering anything, this is the deductible. Once the deductible is met, the insurance company will pay a portion of covered services, leaving the patient to pay their portion, this is know as a copay or coinsurance. Once the insurance company has paid out whatever their annual maximum is towards any dental care received, such as cleanings, exams, fillings, Xrays and more, then the patient must pay for anything else themselves. This means that insurance companies have limited risk when it comes to covering dental needs for patients.
There are plenty more concepts and detailed points to understand about dental insurance policies. There are more resources available: you can call your dentist office to get estimates of prices and explain things; you can read information from the ADA and other non-biased parties, and you could even call your insurance company. However, remember that your dental insurance company has a motivation of wanting to limit how much money they spend on patient care, in addition to phone reps that are typically in entry level positions with minimal training or experience. Remember, insurance companies aren’t in the business of losing money. Always be sure to cross reference any information you receive that is unclear or may seem biased.
We encourage our patients to be informed of their options and to add up all up all costs associated with care and insurance to be able to choose the most beneficial option available.
Always remember that the cheapest, most conservative and most holistic dental care possible is a healthy diet, lots of plain water, and regular brushing/flossing habits.