Better Understand Your Dental Insurance

Category : Insurance

This article will help you to better understand your dental insurance coverage by giving you examples of you possible out-of-pocket expenses and explaining what certain terms mean.

Your Dental insurance and Medical insurance can be very different, so please do not assume they work the same way.
One of the most challenging items for people to understand is the idea of the UCR (Usual and Customary Rate).

The Usual and Customary Rate is what a dental insurer deems as being the median cost for any particular dental procedure. This means that even if your dental insurance policy states that they will pay 100% for a certain procedure, what your dentist charges for that same procedure may be more than the UCR, leaving you with some out-of- pocket expense.

The following examples are for those patients that have PPO dental plans and can go to a dentist of their choice.

ex1: Many dental insurances state that they pay 100% of preventative procedures such as cleanings. This doesn't mean they pay 100% of what the dentist charges for cleanings, it means they pay 100% of the UCR.

-Dentist charges $200. 00 for cleaning, exam and x-rays
-Insurance pays 100% of the URC which for them is $125. 00 for cleaning, exam and x-rays
-Patient out of pocket expense = $75. 00

ex:2 The same idea is applied to basic restorative and major restorative, but usually the percentage on payments changes.

Dentist charges $825. 00 for a crown. Insurance pays 50% of the URC, which for them is $600 for crowns
Patient out of pocket expense = $525 (600 x . 50 = $300, $825-$300 = $525)

For those of you who are going to an IN-Network Dentist, it works the same way but usually your out of pocket expense is less. This is because you are only paying the percentage of the UCR that is not paid.

The insurance company pays 50% of the UCR for a $600 crown, which is $300. Your out of pocket expense would be $300.

Deductibles: Most Preventative services are not subject to a deductible. Any basic or major restorative, or orthodontic is usually subject to the deductible.

Many individual plans have a $50. Deductible and Family Plans have $150 deductible. If a patients goes in for a cleaning, exam and x-rays they will not have to pay the $50 deductible, but the minute that they come in for any fillings, crowns, root canal, etc. , the deductible will be added to the cost.

Yearly Maximum: This is the amount the insurance will pay out in a year for each individual whether you are one person or three people. Each person has their own yearly maximum.

Waiting Periods: Means that certain insurances will not cover certain procedures until you have had their insurance for a year or more.

Missing Tooth Clause: Means that the insurance will not cover for bridges, partials or implants for teeth that were missing prior to patient getting the insurance.

One last word of advice. . . make sure that your read your dental benefits and try your best to understand them; know what procedures are considered preventative, basic and major restorative. It is very important that you understand your benefits so that you have no surprises.