Category Archives: Dental Benefits

Self-Funded vs. Employer-Provided Dental Insurance

by Sam Morgan, Practice Administrator

The world of insurance is ever changing. Even those of us who work in the medical field can find it hard to understand and work through insurance on a daily basis.

The New Year has come and open enrollment season is over so, you either have the dental insurance you had last year or you have something new. Either way, you may find yourself asking the question, why doesn’t or why didn’t my insurance cover that procedure?

First, you need to ask yourself one question: Is this a self-funded policy or is this a policy provided through you or your spouse/significant others employer? 

If you answered that you have a self-funded policy you need to review three big items in your policy: 

  1. Covered Services
    Almost every self-funded policy is going to have substantial LIMITATIONS on covered services. Most of them only cover dental diagnostics and preventative care. If you have or are looking to a plan like this to pay for implants, gum grafts or deep cleanings, you are probably going to find that these are NOT covered services.
  2. Waiting Periods
    Almost all of these policies have 6–12 month waiting periods for anything more than dental diagnostics and preventative care. While they may cover implants, deep cleanings or gum grafts, they are not going to cover any of that until you have paid into the policy for at least 6–12 months.
  3. Annual Maximum and Deductible
    You need to make sure you understand what your annual maximum is for your covered period. Once you understand, you will be able to assess whether or not it is a good decision for you to carry a dental benefits/insurance policy. If what you are paying is almost equal to what you COULD get back from your plan each year, you may want to consider dropping the plan and simply putting that money aside for a rainy day.

If you have a policy issued through an employer, you need to understand that your EMPLOYER has pre-negotiated rates and terms for the policies available to you — and ultimately your EMPLOYER controls what your plan covers. Look into the following points to get more clarity: 

  1. Frequency
    How often can you have a procedure? This is common with cleanings, deep cleanings and the placement of a prosthesis.
  2. Missing Tooth Clause
    A missing tooth clause is a stipulation in a policy that will only allow coverage for an implant if the tooth is extracted under that plan. So, if you had a tooth extracted prior to your current insurance contract, your new carrier may not cover the implant procedure.
  3. History
    Your dental history can work for or against you when get a new carrier. Carriers can decided whether or not they want to pull information about previous procedures when making the decision to pay or deny a claim.
    For example, to get a periodontic maintenance procedure covered, you have to have documentation of a previous periodontal surgery from your previous carrier. Or let’s say you want to have an implant placed with a policy that only allows the placement of 1 prosthesis every 5 years. If you have had a crown placed on that same tooth under another plan in the last 5 years, your carrier may not pay for the new implant because they picked up the history from your previous carrier.

Regardless of whether you have a self-funded plan or an employer provided plan, review all these points and apply them to your situation. Never be afraid to ask questions of your provider (Dentist), the Carrier (Insurance Company) or your HR Department at your employer, and always ask for a pre-authorization for costly procedures if time permits.

Why Dental Insurance Really Means Dental Benefit

by Sam Morgan, Practice Administrator

If you don’t work in healthcare — or even if you do — you may not understand your dental insurance. I know I didn’t understand any of my benefits when I worked in the corporate world.

It is very commonplace and normal to think that if you have dental insurance, you should be covered for your normal hygiene maintenance procedures and any needed surgeries. Unfortunately, this is not the case. So, let’s take a few minutes to review some dental insurance basics:

  1. Dental insurance is really a dental benefit that is allotted to you each year. These benefits usually run on a calendar year but sometimes run on different 12 month cycle.
  2. We call dental insurance a dental benefit because, unlike most health plans, there is a defined or limited amount of benefit available to you each year.
  3. Coverage for dental benefits under companies, plans, and groups will vary. Dental benefits are most commonly covered at a percentage of the fee charged by your dental professional. For instance, Sally may have 80% coverage with Company A for a cleaning while Bill has 60% coverage for the same cleaning under Company B.
  4. Routine cleanings, exams, and x-rays are all covered at different levels within dental insurance companies. You should be aware of frequency limitations in the number of times per year (or any defined time period) that these services can be performed.
  5. To find out exactly what may — or may not — be covered and at what percentage it is covered, you may want to request that your dental professional file a Pre-Authorization or Pre-Determination prior to a procedure. This is a recommendation based on procedure code and your dental insurance company requirements.
  6. You should receive an Explanation of Benefits (EOB) each time your dental Insurance is billed for a procedure. If you don’t receive this information, you should contact your dental insurance company for a copy. If you have any trouble understanding your EOB, I recommend that you contact your dental professional for help understanding the document.
  7. Common language you may hear in a dental office, on the phone with your dental insurance company, or see on a Explanation of Benefits includes
  • Dentist = Provider
  • Insurance Company = Carrier
  • ADA Code = Dental Code, a four digit number that follows a D (e.g., D0120)
  • EOB = Explanation of Benefits
  • Maxed Out = patient has utilized all of their benefits for the year
  • Frequency = number of times a procedure may be performed within a defined time period

The bottom line is that insurance is constantly changing, and it can be very complicated to understand. However, it is important to understand your benefits. Ask questions of your carrier and your provider. Don’t be embarrassed if you don’t understand or even if you need it explained more than once.

Each year, you may go through Open Enrollment at work. Take that opportunity to speak with your HR department and your dental professional about the options available to you.