With the New Year, many insurance plans will “re-set” with the calendar year. We, therefore, encourage all patients who have insurance coverage to read and understand your insurance plan information that your employer has elected and contracted with the dental insurance company. That contract dictates your coverage guidelines as negotiated by your employer. Please keep in mind that just because you have the same plan as last year, it may not mean you have the same coverage. The language in these plans is always evolving and can be very confusing to navigate.
In our desire to help you, we would like to provide you with some questions you should ask as well as terminology should they appear in your plan. We can hep you understand your general benefits as it pertains to your proposed treatment, but we do not know the specifics of every dental plan.
What is your plans’ yearly maximum?
Look for changes in your yearly maximum for an in-network vs out-of-network provider. Find out whether hygiene appointments apply to this maximum. They may not be used to, but now, for many plans they do.
What is your plans’ deductible?
A deductible is an amount that you yourself is responsible to pay out-of-pocket before your insurance benefits will take effect. Contact your insurance carrier to find out how much your deductible will be.
Is there a missing tooth clause?
If you are missing a tooth prior to having insurance coverage, dental companies may deny coverage for replacing those missing teeth; it is considered to be a ‘pre-existing’ condition. Whether you plan to replace your missing teeth with bridges, implants, or dentures, check your policy.
What is the frequency of coverage?
Many insurance carriers dictate a frequency of coverage clause for procedures. This pertains to the frequency at which they would redo or replace a procedure or prosthesis. In most cases, for dentures, partials, crowns or bridges, this frequency tends to be every 5 years, but check your individual policy.
Are alternative benefits available for restorative treatment?
Previously called “downgrade benefits”, this alternate benefits clause has made its way into many policies. As alternative benefit means, your insurance company may downgrade and pay for silver restorations, but not tooth-colored restorations. This is becoming more common. These ‘alternatives’ are an old style of restoration and do not keep up with the up-to-date trends in dentistry.
Is there a waiting period for treatment?
Plans have added clauses prohibiting treatment in the first 6-12 months after initiating coverage. Most limitations apply to crowns and bridges. Please check your individual policy.
At Integrated Dental Care, we offer an in-house plan that eliminates much of the inconveniences of conventional insurance plans. Call us to find out how we can help.