Do you know what does your insurance covers?
As a leading dental office in Plantation, Florida not a day goes by where a patient is surprised about what their dental insurance covers and what it does not. When talking about dental insurance, it is important to point out that most dental needs fall into three categories: Basic, major, and preventative. For the most part most all preventative needs are covered but at a minimal level. For example, if you need your teeth cleaned (simple prophylaxis or tooth polishing with some light calculus removal) is covered, but if you have not had this done for over a year, and have as your clinical condition extensive tartar build up, you insurance may not cover this at 100%. You can expect that you will have a co-payment for this service as it is not a simple cleaning. These specialized cleanings are very important. Please understand that this is a deeply discounted fee from the UCR (usually and customary fee) but it is not free.
Major services are usually covered at 50% but under limitation fee guidelines. For example, if you break a tooth and need a crown, the out of pocket cost could be $1000. At 50% coverage on this, you might expect the carrier to pay $500 of this cost; however they have an internal schedule. This means that they will only cover the cost of a crown up to 50% of $700, or $350. The result is a copay on the patient’s part of $650, more than the 50% cost of the procedure. It is important to understand how this works, and it can be confusing.
Finally, most indemnity plans have a yearly payout limitation. No matter what you need for dental care, they will pay up to $1000 for this treatment. The amount depends on each plan.
Sometimes they may not even approve the necessary treatment, even after the doctor and patient agree upon treatment, and only approve a less expensive alternative that their administrator feels is appropriate. Decisions such as this may lead one to inquire what dental school and clinical basis Mr. Administrator/claim reviewer have for making this decision, and possibly appeal it. However, these are the limitations of dental insurance, and hopefully, give an insight into why coverage may not be what you anticipate, and hence additional cost to your treatment needs.
At Gentle Family Dentistry in Plantation, Florida our Doctors and staff have over 35 combined years of experience in the dental industry. We will attempt to maximize you insurance benefits, and will do our best to lower your out of pocket costs as much as possible. We understand the insurance industry, and will attempt to provide you with the very best treatment options, and provide you with the best care for your dental dollar.