So many of our
patients are coming in with questions about the changing dental insurance
environment and voicing their frustrations with their dental insurance. The dental insurance environment has changed
drastically in the past two years.
Hopefully this information will help answer some questions.
Medical
versus Dental Insurance
Medical
insurance is designed to protect you in a worst-case scenario. You pay a monthly premium but tend to be
covered in case something serious comes up, such as an emergency or an
unforeseen surgery. Dental insurance is
significantly different. Instead of
having copays and monthly premiums, many dental insurance plans only cover a
percentage of certain dental procedures on top of the monthly premiums. Most plans (although not all plans are this
way) cover 100% of preventative care, such as cleanings and x-rays, 80% of
basic procedures, such as fillings and root canals, and 50% of major
procedures, such as crowns.
Additionally, dental insurance plans tend to have a yearly maximum around
$1000 - $2000 that requires the patient to pay the whole amount of procedures
done after reaching the yearly maximum.
Most dental
insurance plans cover a percentage of certain dental procedures (that
percentage being anywhere from 10% to 100% depending on the procedure and the
plan). That percentage is only covered
after the plan’s yearly deductible is met (this usually runs about $50-100 but
can be as large as $300-500 for some plans).
Most plans used to cover 100% for preventative treatment; it is now
evident that this is no longer the norm.
We are seeing more plans that have dropped their preventative coverage
to 80% and their basic coverage to 50%.
Best
Case Scenario
During a good
year, you may only need preventative care in the form of cleanings, exams, and
x-rays but you will still lose $200 by having dental insurance. Although these services are typically paid by
insurance plans, you would probably still be losing money overall by having the
insurance. For example, two hygiene
appointments for the year would amount to about $400 if you paid out of pocket
for these services. The insurance
company’s premiums for the year, without needing more than just preventative
services, would amount to about $600 alone.
Worst
Case Scenario
Now, you might
be thinking that insurance may still be worth losing $200 a year if you are covered
on the years when you need more than just a check-up. Unfortunately, that may still be untrue. Let’s consider a patient who needs two
fillings, a root canal, and a crown on top of normal, yearly cleaning
appointments. One would hope that
insurance would cover more of those services since you pay about $600 in
insurance premiums but the plan also has a yearly maximum of $1000. That means
that once you meet the $1000 max, you are stuck paying the rest completely out
of pocket.
Although you
may receive lower negotiated rates for basic and major services due to
insurance, those rates aren’t much lower than the dentist’s normal fee. For
example, if the dentist charges $150 for a filling, your insurance company may
only have negotiated the rate to $100. In this case, your exams, cleanings, x-rays,
and basic work such as the fillings would most likely utilize your insurance
yearly maximum. That leaves you to pay
the $1000-$2000 extra for the crowns and root canals, which is all on top of
the $600 in annual premiums.
Waiting
to Get Insurance or Services
It
may seem like a good idea to wait to get dental insurance until you really need
it but insurance companies have a clause for individuals who do just that. There is what is called a “waiting” or “probationary”
period where they will not cover certain services for the time period after you
get the insurance. Most plans will not
cover crowns or any other major work for at least twelve months after getting
the insurance and for some plans this also includes basic work like fillings or
root canals (which are often needed in emergency situations).
Waiting
to get the services may not be such a good idea either. Many of the situations that require a crown or
other major work are cases in which it is impossible or possibly detrimental to
your overall health to wait. For
example, if a tooth were cracked, crowning it is a way to reduce the pain it is
causing, as well as strengthen the tooth to prevent possible future fracture. If the tooth were to fracture it often times
fractures in such a way that the fracture extends up under the bone level where
it can no longer be reached and fixed, therefore the tooth has to be extracted
and then you are looking at trying to replace that tooth, which could many
anything from removable partial dentures to fixed bridges to implants, none of
which are inexpensive options. Insurance
companies know that certain services are unavoidable, hence the reason they
have the waiting periods to discourage people from getting the insurance only
when they need major work.
Closing
Thoughts
Dental
insurance is continually changing and not necessarily to the benefit of the
patient. Many individuals have begun to
see how having dental insurance may not be beneficial, but instead may cost
more money and cause more headaches.
This post is in no way intended to persuade readers to refrain from
going to the dentist but is instead to discuss the current field of dental
insurance. As always, it is recommended that individuals brush twice a day and
floss once as well as engage in other activities that help keep your oral
health on track so as to not need the more invasive dental procedures.
We, as
providers, often receive complaints about a patient’s dental insurance and the
coverage they receive for the dental treatment they need. While we will try to answer the questions to
the best of our ability, sometimes your insurance carrier is the best place to
go for an answer. If you are not happy
with the answer you receive from carrier, you should take your questions and
concerns to the Human Resources Department of your employer. Dental insurance plans and their benefits are
chosen by the employer. If the employer
does not know of coverage issues, they will not be able to select a plan that
better covers the needs of their employees,
Source:
Fontinelle, A. (2014). Should you
bite on dental insurance. In Investopedia .
R. Eric Emery, DDS
Morgan A. Emery, DDS
2901 Dougherty Ferry Rd, Suite 400
St. Louis, MO 63122
(314)821-7100
