Insurance & Financing Options

There are many variations of dental plans, and most benefits are set by the employer, but typical PPO plans carry the following scenarios:

• PPO stands for Preferred Provider Option... this type of plan allows you to see any provider of your choice whether they are considered in-network or not. 
• ANNUAL MAXIMUM- Yearly maximums range from $500-$5,000.  This the total amount your dental plan will pay during a 12 month period.  Your plan may cover only a percentage of each treatment up to this maximum amount.  The benefit year may be a calendar year or a fiscal year depending on how your plan is structured. Once your new plan year begins, your benefits are replenished back to where you started.  Unfortunately, if you don't use your benefits, you lose them as they won't roll over to the next year.  
• ANNUAL DEDUCTIBLE - Annual deductibles typically range from $25-$150.  This is a plan year amount paid by you and must be met before benefits are paid on certain services. This is collected by the dental office at time of service.  Many dental plans do not require you pay this deductible during your initial diagnostic and/or preventive visit (routine cleaning, x-rays, exams), but it will kick in when you have other treatment performed.  
• FREQUENCY LIMITATIONS - This is the number of times your plan will cover a certain procedure within your plan year. Frequency limits are put into place by carriers as a way to control their costs and limit the amount in benefits they are obligated to pay out.  This should not be construed as a way in which they are dictating treatment... only you and your provider know the treatment you need and how often you need it.  For example:  Many plans allow 2 dental cleanings per plan year. This is typically what a patient with healthy teeth and gums will need, but sometime, a patient needs a professional dental cleaning more often in order to improve and/or maintain their oral health.  If this is the case, the patient may incur the 3rd cleaning out of pocket.  Some plans will allow more cleanings if perio disease is present, during pregnancy, or while wearing braces.

• CO-PAY or PATIENT SHARE- Your Co-Pay or Patient Share is the percentage of the treatment you must cover that your plan will not.  For example, if the fee is $100 and your plan covers 80%, your share would be $20.  Unfortunately, some dental plans may reduce the benefit they will pay leaving you with a larger balance. When dealing with more expensive procedures, it's best to ask your dental provider to send in a pre-treatment authorization prior to treatment, so you can be certain of your share.

• OTHER WAYS DENTAL CARRIERS CUT THEIR COSTS... DOWNGRADING BENEFITS ON FILLINGS/CROWNS/ONLAYS - Many plans will downgrade the benefit they'll pay for fillings and/or crowns/onlays to "lesser materials."  This means they'll pay a lesser amount on a lesser quality procedure, but will still pay some benefit.  For example:  White composite fillings on back teeth are commonly downgraded to the old amalgam material (silver fillings).  Again, this is not the dental carrier dictating that the filling should have been an amalgam, rather it's the carrier's way of cutting their costs by paying out less in benefits. 

• Unfortunately, when the carrier does this, the patient is left with the remaining bill.  Frequency limits will also apply.  

• Average limit for Fillings - 2 years, for Crowns/Onlays/ Bridges - 5-10 years.

• COSMETIC vs. CLINICAL NEED - Most plans will not cover procedures for cosmetic purposes.  

• MISSING TOOTH CLAUSE - Many plans impose a "missing tooth clause" which means they may not cover a procedure involving a tooth that was missing prior to the plan starting.  

• WAITING PERIOD- Many plans will impose a waiting period on select services within the first year of starting.  This is especially true with individual dental plans.

• EXCLUSIONS - Many plans will not allow certain services.  When in doubt, ask us!  We'd be happy to check for you!