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.

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