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Dental Insurance – Things You Should Know

I’m often asked one of two questions about dental insurance.

  1. What is the best insurance? I answer – the one someone else pays for!
  2. Why isn’t Jason Hutto, DDS on my insurance plan? Answering this question is a bit more complex and in the following article I will give my reasons for choosing not to work for an insurance company.

What is dental insurance?

Dental insurance is a form of health insurance designed to help offset the cost associated with dental care. It’s not truly insurance but a form of prepayment for dental work with exclusions. There are many, many forms of dental insurance which I will not cover here, but I highly recommend patients take the time to find out what type they have and the procedures they cover and don’t cover.

What are some common characteristics of dental insurance?

Unlike health insurance, dental insurance plans have a yearly maximum and once that maximum is reached, all remaining expenses will be out of pocket costs for the patient. Unfortunately for patients, this yearly maximum has not changed since the early 1970’s. It would stand to reason that since yearly maximums have not risen, neither have yearly premiums. As I am sure you are aware that is not the case.

Can you think of anything that costs the same as it did in the 1970’s? Increases in operating costs, supplies and labor – to name a few – have driven up the cost of dental care. Dental insurance companies have failed to keep up with these rising cost. The following graph illustrates how a $1,000 maximum benefit in 1972 compares to the same maximum benefit in 2015, which, by the way, is still the same $1,000 maximum benefit as 1972.

Wait periods for new insurance plans can be anywhere from six months to a year for major dental work such as crowns, root canals or bridges. Preventive care is usually covered at the start of the plan but for patients needing immediate, extensive dental work, dental insurance may be of very little help.

Most plans have a missing tooth clause such that any teeth missing at the time the plan is enacted will not be covered for replacement. Cosmetic procedures, TMJ treatment and dental implants are also common exclusions in most plans.

What does in-network mean?

A dentist that enters into an agreement with an insurance company to accept discounted fees could be considered in-network. In essence that dentist has agreed to work for and allow the insurance company to dictate patient care, in my opinion. For example, a patient comes in complaining of headaches, generalized tooth sensitivity and has obvious wear on all teeth. It is determined the patient is suffering from bruxism which is commonly treated with a “TMJ” splint. This is one of the most common procedures not covered by insurance companies. As a result, the patient decides not to have the splint made, since it’s not covered by their dental insurance. Even though the proper treatment is to do the splint the insurance company, by not covering the treatment, has influenced the decision of the patient.

When in-network, the dentist agrees to discount his or her fees in some cases up to 25% or more. The average overhead expense for a general dental practice is around 70%, leaving an average operating budget of around 30%. When fees are discounted at 25% this drops a 30% operating budget down to 5%. This leaves little to no room to cover any unexpected office expenses. Over treatment or unnecessary work may be treatment planned to cover this shortfall. Unfortunately I have seen this from some practices that are heavily insurance based. So my advice to patients is to seek a second opinion if a lot of unexpected treatment is recommended.

Dental insurance is nice to have but should not dictate your dental care. Although dentistry can be expensive, there are a number of options available to make it fit any budget like CareCredit and in-office discounts Ask your dental office what financial options are available as they should be eager to help you achieve optimal dental health.


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