A few things to know about dental insurance. Please keep in mind that there is a difference in employer dental benefits and individual dental benefits.
There are several types of plans:
Flat Fee: The insurance company pays a flat fee for each given service.
Fee Schedule: This is when the insurance company pays a given percentage for a service; you are responsible for the rest.
Maximum Allowable fee: The maximum fee allowed to be paid for a service by the insurer for an in network service. This allows for less of a balance bill at dentist out of network.
In Network fee: The fee schedule in which the in network average fee is paid by the insuerer for a service. Out of network you are more likely to have a balance bill.
There are four classes of services: Preventative (Class I), Basic (Class II), Major (Class III) and Orthodontics (Class IV).
The coverage under each of these services tends to vary by carrier and plan type
There is typically no deductible on the Class I services (unless your plan has a lifetime deductible rather than an annual deductible)
Class II and III typically have a combined annual deductible, in other words, if you pay the deductible in Class II you will not pay it again in Class III.
Class IV services typically do not have a deductible, but rather a waiting period and a lifetime maximum (a cap on the amount a carrier will pay out in someone’s lifetime). Generally, these benefits are only applicable to those under 19 years of age. Not all plans have Orthodontics available, but if this is available, this class is usually an added rider at an additional cost.
Examples of services:
Class I – cleanings, x-rays, fluoride (within an age limit)
Class II – fillings, simple extractions, root canals, periodontics, endodontics, etc.
Class III – crowns, bridges and dentures
**Some plans will put root canals, endodontics and periodontics in Class III, which sometimes may mean less will be paid by the insurer for these services, and/or there is a longer waiting period before they are covered.
Employer paid dental benefits tend to only have a waiting period (period of time you must have the insurance before the carrier will pay anything on the services) on major services, and sometimes employers can pay extra to have these waiting periods waived.
If an employer moves to a new carrier that has a waiting period, will you have to undergo that waiting period again? No, the length of time you have satisfied for that waiting period will carry over with you if the employer submits proof of prior coverage. However, if for example, your prior plan did not have orthodontics and the new plan does, you will have to undergo the waiting period since it was not satisfied under your prior plan’s benefits.
Individual dental benefits tend to have a 6 month waiting period on Class II services and a 12 month waiting period on major services. These waiting periods will usually not be waived.
Are there in and out of network benefits with dental insurance? Yes, you can have a PPO type plan, which will cover you in and out of network or an HMO/EPO type plan that will ONLY cover you in the network. Make sure you know if your dentist is in the network. Sometimes a dentist will say they participate with a carrier, but that does not mean that they are in the network. It simply means they will submit the bill as out of network and accept the insurer’s payment; but you may still owe money.
If you have a PPO plan and you seek services out of the network, you may have a balance bill. When a dentist is part of the network, it means that he/she agreed to charge no more than a certain amount for a service (usually called a reasonable and customary charge); whereas, when you go out of network, the dentist does not have this agreement, so they may charge more than the insurance company pays for the given service, which leaves you with a balance bill.
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