Dental Insurance Explained: Understanding Coverage & Co-Payment
A tooth stands beside ascending piles of coins
READING THROUGH DENTAL insurance plans can be unfamiliar for many, especially those using their benefits for the first time. It's important to have an idea of your dental coverage ahead of a scheduled appointment. However, we know insurance jargon can get a little confusing! If you would like to get a better understanding of how dental insurance works, keep reading!
Please keep in mind that this post is here to help answer general questions. Your employer and an insurance representative can answer questions that relate specifically to your plan.
What Is The Patient Responsible For?
Insurance coverage is an agreement between the insurance company and, typically, your employer. In Ontario alone, there are over 30,000 dental plans that are unique in their benefits! Some plans cover as much as 100%, while others cover as little as 10%. So it is important to have an understanding of your plan ahead of scheduling an appointment.It is also important to know that your insurance may not base your coverage on the current year's fee guide. For example, our office follows the current Ontario Dental Association fee guide which can change each year.The amount of coverage negotiated with your insurance company does not involve the dentist. Patients are responsible for unpaid portions of dental procedures (co-payment). Patients need to cover the costs of any procedures that their plan does not cover.
Waiving the co-payment is not allowed. Contrary to what some patients believe, dentists cannot waive the co-payment fee. It is insurance fraud. Insurance fraud can harm not only your dentist but also you and/or your employer.
What Is The Dental Clinic Responsible For?
Your dental clinic will provide you with the available treatment options that best address your dental needs. Your dental health state determines your treatment plan, not your dental plan's frequencies and limitations.
Dental pre-determinations, also known as dental estimates, can be submitted by the dental clinic to your insurance provider. Estimates are a request to insurance providers. In other words, it asks them to notify the patient of their expected coverage for procedures in their treatment plan.
The policyholder (insured) will always receive a copy of the response. Therefore, the patient is responsible for checking their estimate responses and knowing their coverage before an appointment.
There some cases where the insurance provider will contact the plan administrator for more information. For instance, procedures like crowns, implants and Invisalign usually require more information.
The plan administrator will then ask you to request this information from your dentist. The dental office will provide you with the information you request. Still, it is ultimately your responsibility to provide this information to your plan administrator.
Dentistry provides tender loving care for your teeth and gums
Paying Upfront vs. Paying The Difference
It is common for patients to wonder if they need to pay upfront for dental treatment (and get reimbursed by their insurance) or if they should simply pay the difference.It depends on the plan! For example, some plans allow assignment of benefits (paying the difference) while others are non-assignment (paying upfront).While there are dental practices that do not accept assignment of benefits, our office does! Again, this depends on your plan. If your plan allows assignment of benefits, our reception team can help submit your dental claims. After, we collect the out-of-pocket portion not covered by your dental plan.
Primary and Secondary Dental Insurance
Some patients have two plans. Please let us know if you are listed under your partner's plan (in addition to your own). If you are a student (over 18) under a parent's plan, you need to let us know, too! We need to know the name of the university or college you attend. We'll also need to know if you are a part-time or full-time student.When you finish your appointment, our team will send out a claim to your primary insurance provider. If the primary insurance covers less than 100% of the services, we submit the response to the secondary carrier. The secondary insurance will need to consider the primary coverage to assess the claim. The patient is responsible for any remaining balance not covered by both plans.
We Are Here To Help!
A patient fills out information for his dental insurance claim
Our goal is to make sure that we offer you the best dental treatment possible. Dental benefits were never meant to provide the best possible care - they are there to assist you in your treatment of choice. Remember - a dental insurance plan is not a treatment plan! If you have more questions about your dental coverage, your employer and/or insurance provider can answer any specific questions.
Want to read more? Check out this great summary on dental insurance by the Ontario Dental Association.
Want to see if you're covered? We can submit an estimate on your behalf if you're a current patient. All you have to do is ask! You can read more about the kinds of procedures covered by insurance in our end-of-year article for 2020.
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The content on this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of qualified health providers with questions you may have regarding medical conditions.