The Details on Dental Insurance

Approximately 250 million Americans have private dental health coverage, and around 83 million receive dental benefits through public health programs such as Medicaid. That leaves some 74 million Americans with no dental coverage.

Dental health insurance plans typically focus on prevention and follow a 100-80-50 coverage rule for what the insurance company deems usual, customary and reasonable charges. (Your dentist’s actual charges may differ from what the insurer deems to be usual, customary and reasonable; therefore, it is not guaranteed that the insurance plan will pay the complete charge.)

Typically, a plan aims to pay 100 percent of the cost of routine preventive care, 80 percent of the cost of fillings and other basic procedures, and 50 percent of major procedures such as crowns. Plans tend to cap coverage at $1,000 to $1,500 per year. Cosmetic procedures are rarely covered.

If an employer doesn’t offer dental coverage, is it worth it to pay for it yourself? The National Association of Dental Plans estimated in 2014 that plans charged employers annual premiums of $228 to $314, and the cost of buying an individual policy was around $350. In 2013, the average American paid $544 in out-of-pocket dental expenses.

There are three types of dental insurance: HMOs, PPOs and indemnity plans. An HMO (health maintenance organization) plan restricts coverage unless the patient sees a dentist within a limited network. An indemnity plan allows the patient to see any dentist, and it typically picks up a percentage of the costs. The most popular type of plan is a PPO (preferred provider organization), which pays more if the patient sees a dentist within the “preferred” network of dentists that the insurer has negotiated with for reduced rates.

At Enlighten Dental Care, we choose not to participate in any networks because the insurance contracts are convoluted and can be changed without our authorization. In addition, the negotiated fee schedules are often well below what a small business needs to charge in order to run the business.

As a courtesy, our office does file insurance for patients once we verify that the insurance contract is in place. However, we ask that patients pay their estimated portion up front because, oftentimes, the insurance company will send the payment back to the patient instead of the dentist’s office. We will file insurance for our reimbursement on covered procedures as well.

With third party finance companies such as CARE CREDIT, we prefer not to dilute the doctor-patient relationship with a financing agreement. We would rather worry about the clinical issues and let the finance company assume the risk for payment arrangements and collection.

Enlighten Dental Care also does not accept Medicaid. Instead, we choose to do pro bono dentistry with people involved in numerous local ministries who are trying to make a difference, on an individual basis, in people’s lives.

If you have questions about dental insurance or payment, please contact us at Enlighten Dental Care at (336) 765-0904

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