If you have dental insurance, you may think you’re covered when you go to the dentist. Unfortunately, that's not always the case. It depends on the type of insurance plan your employer has designed with the insurance company.
Here is a list of questions you should ask your dental insurance provider so you know exactly what will be covered by your insurance, and what you will be expected to pay out-of-pocket.
What type of cleaning is covered?
Many patients think their insurance will cover two "free cleanings" a year. However, many insurance plans will only cover the cost of a healthy-mouth cleaning. If you're part of the 75% of the American population with periodontal (gum) disease, then you need to ask your insurance plan if it will cover your treatment. Specifically, ask if your insurance will cover a deep cleaning, debridement or scaling and root planing (SRP) if deemed clinically necessary by your dentist. Also, ask if your insurance company will cover the costs of your visits for periodontal disease management. Your dentist's office can give you the American Dental Association (ADA) codes to give to the insurance company to make sure you know the exact out-of-pocket costs associated with any procedures.
Is there a waiting period for major procedures?
This is a big one! Some people sign up for dental insurance because they know they need a crown, implant, denture or another major procedure done. However, some insurance plans require you to have coverage for a year before they will cover the costs of even an emergency treatment like a root canal. A root canal for a molar can cost more than $800 out-of-pocket; if you add in the cost of the tooth preparation and the crown, it can cost more than $1,500.
What type of filling is covered?
Some insurance companies will only pay for amalgam, or metal, fillings. However, because of the mercury in these kinds of fillings, many dentists will not use amalgam fillings and will recommend a mercury-free white resin composite filling instead. If the amount of tooth decay is more than what a regular filling can replace but less than what would require a crown to repair, then your dentist may recommend an inlay or onlay. Both are well-suited for large cavities, but they are more expensive than regular fillings. Ask your insurance company if it will cover the expense.
What materials are covered for major procedures?
Some insurance companies will only pay for the least expensive treatment for a condition, even if your dentist prescribes something better. Let's say you need a crown. Ask whether your insurance company pays only for non-precious metal or semi-precious metal crowns. These crowns often carry a warranty of one year or less and can cause dark lines around the gums. Your dentist may prescribe higher-quality, more-durable precious metal or all-ceramic crown based on the location of the missing tooth and expected wear. These crowns look more like natural teeth, can take heavy wear and carry longer warranties.
Will your insurance cover all the treatment associated with the procedure you need?
Ask your dental office for a copy of the treatment plan and a breakdown of the benefits sheet. Then call your insurance company and go through each step that is outlined. Many insurance companies will not cover the cost of the fluoride treatment, which remineralizes the teeth and helps prevent cavities, for example. In other cases, the insurance company may cover the type of procedure, but not the number of treatments you require. It may help cover the cost of antibiotics for only two teeth per quadrant, for example, or only provide insurance for up to four fillings. Be sure to ask if there is a frequency restriction.
Is there a missing tooth clause?
Yes, you read that correctly. You may sign up for dental insurance because you have a missing tooth, which if left empty, can cause your other teeth to shift, affect your bite, lead to bone loss and cause your facial muscles to sag, which makes you look older. However, some insurance companies treat a missing tooth as a “pre-existing condition” and may not pay for the treatment necessary to restore it.
What does the fine print say?
Your employer or your dental insurance company should provide a copy of the fee schedule to you. If there is any kind of a symbol such as an asterisk next to the code, you need to read the fine print to see what that symbol means. Often, it’s stating there will be out-of-pocket expenses for the patient.
Will a specialist's fees be covered?
Your insurance company may cover a procedure performed by a general dentist at one rate, and the same procedure performed by a specialist dentist at a different rate. It’s important toknow what percentage of your cost will be covered should you need to see an oral surgeon, endodontist, periodontist, orthodontist, or pediatric dentist.
Will changing offices affect your out-of-pocket costs?
If your employer requires you to relocate, or if you choose to change dental offices, it could affect your out-of-pocket costs for dental care. A procedure in New York City typically costs more than a procedure in a small town. Your insurance company sets the rate for what it will pay for each location, and that can vary zip code to zip code.
Is there a deductible and/or a co-pay?
Ask your dental insurance company about your co-pays or deductibles before you visit the dentist. Your out-of-pocket fees depend on the type of policy your employer has negotiated with the dental insurance company. Many employers are paying less toward insurance coverage, which requires the patient to pick up more of the cost.
Taking the time to ask these 10 questions will help you understand your dental insurance benefits and the procedures your company will cover to give you a beautiful and healthy smile.
Written by: Beth Gaddis
Reviewed by: Tim Hill