**Think of dental insurance as a bonus. You should not allow your insurance company to dictate what you do for your health. When given treatment options, you should weigh the pros and cons of each in terms of what will give you the best health outcome for the longest — that you can afford. We do realize that finances are a factor, and you may need to save up for a particular treatment, but try not to let your insurance company drive your decision. They only want to cover as little as possible, so they may not offer coverage or they may offer only little coverage, on a treatment that you really need for your dental health. Just because an insurance company does not cover a procedure does not mean they are saying they don’t think it is a beneficial procedure. It just means that the particular procedure was not included in the benefits package at the price point your employer chose — or that you chose if you have a private insurance plan.**
Dental plans can be confusing to understand. For example, you may think that if your plan only allows one checkup (recare) per year, that you can only have one cleaning per year. That may simply not be the case! Scaling and polishing are both measured in units of time. Your insurance plan, for example, may allow for 1 unit of polish and 12 units of scaling per year. Divided up, this could mean 2-3 cleanings worth of scaling (this entirely depends on how much buildup you have and how long the hygienist needs to remove it all), and you may be able to use only a half unit of scaling per visit depending on how much staining you have (you might have to pay the full amount for the polish or skip it for one visit if you come 3 times a year). You may easily be able to come twice a year and have your benefits cover it! Regular cleanings help keep your gums healthier and buildup at bay, which will help prevent cavities.
How much will your dental benefits cover of a particular procedure? This is a tougher question to answer. Dental plans vary A LOT. You may have 80% coverage for simple restorative work like a composite filling, but you may only have 50% coverage of more complicated restorative work like a crown or a bridge. For example, a $300 filling covered at 80% means the insurance company pays $240, and you will have to pay the remaining $60. You should also know that not all plans have coverage for more complicated procedures. You should call your insurance company to ask for clarity if you do not understand what the benefits book or website says you have in terms of coverage. We may even be able to help if you bring the book with you to your appointment.
Your plan may say they cover 80% of a filling, but they may be using an outdated fee guide (the price guide given to dentists by their governing body) compared to the dentist you are seeing, so you may notice they list a maximum fee that they will cover up to, and that may very well be lower than the price listed for the service at the dental office. The difference is usually not that much, so it is not a large concern for most people.
When it comes to a yearly limit for your insurance, only the amount of money they pay out to you counts towards it. What that means is if you have a $1500 yearly limit on your plan, and you get a $1500 crown, but they only pay for 50% of crowns, you still have $750 remaining to use for the year, even though the total cost of the crown seemed like it would use up the whole limit. You should also check with your insurance company to see what dates they are using to track your calendar year. Some plans may follow the regular January to December calendar, others may start at a different point in the year.
If a procedure is not covered, or is only partially covered, you can claim the amount or remainder on your income taxes as a health expense so long as it was not considered cosmetic work (ie whitening, veneers). If you do not have dental benefits at all, you can claim all of your non-cosmetic dental work, including cleanings, on your taxes. So hold on to those receipts!
**At our office patients pay for the treatment upfront the day it happens (fee for service), and then we electronically send your dental insurance to your provider so that they can pay you the total amount that they cover.**