Jul 09, 2024

How Do I Get the Most Out of My Dental Plan?

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    Ask an Advocate

    How Do I Get the Most Out of My Dental Plan? 

    Not all dental coverage is equal. This is why it’s important to become familiar with the details of your dental plan before you schedule that expensive dental procedure or treatment.

    Here are some FAQs and tips on how to understand your dental coverage and lessen the impact of expensive dental work on your wallet.  


    In-network versus out-of-network dentists: You can save $$ by using an in-network dentist!  

    • In-network providers have agreed by contract to accept the reimbursement rate set by the insurance company, and they cannot charge you an additional amount.  
    • Out-of-network providers will, in most cases, bill your insurance company but are not required to accept the insurance’s reimbursement rate as payment in full. Out-of-network providers generally charge you the difference between what they billed and what the insurance company paid them. So, if you really love your out-of-network dentist, be prepared to pay that extra amount. Talk to the billing department at your dental provider ahead of scheduling to get an idea of what that difference may be.  


    Know how your plan works: Summary of Benefits

    Before accessing services, please check your Summary of Benefits (located in your enrollment portal or in your enrollment guide). If you can’t find it, ask one of our advocates at 855-662-1029. 

    This document quickly outlines what percentage of the bill you will pay for services, including: 

    • Preventive Services (typically covered at 100%)
    • Exams 
    • Cleanings
    • Most plans cover one per six months, and some cover three times/year; check your summary for details. However, if you need deep cleanings (periodontal), these are covered under “basic” or “major” benefits (not preventive) and will be subject to your plan’s annual deductible and coinsurance. 
    • X-rays
    • Bitewing X-rays (the ones where you bite down on the mouthpiece) are typically covered as preventative care, but pricing may vary for more advanced imaging like panoramic X-rays, etc.


    Asking for a Pre-Determination 

    Have you ever had a major dental procedure that was not covered for whatever reason? Most likely, there was some small detail, stated in the Certificate of Coverage (COC) under exclusions, disqualifying coverage for that procedure for your condition. So, if you need an expensive root canal, an implant, or a bridge, be sure to ask your dentist to request a Pre-Determination from the insurance carrier. The pre-determination letter will tell you if the services are approved by the insurance company and how much you will owe, whereas your dentist’s estimate does not guarantee coverage or cost to you.  


    Be Aware of the Missing Tooth Clause  

    You may not get your two front teeth for Christmas because of a common dental rule. The missing tooth clause is a dental contract provision that states if a tooth is lost before the contract begins, it will not be the dental insurance’s responsibility to cover replacing the tooth (or teeth) with a crown, bridge, or implant. This clause also applies if the tooth was pulled more than 12 months prior to receiving replacement treatment. 


    Need more ideas on how to pay for dental services? Find out here: 5 Smart Ways To Pay For Expensive Dental Work (abaudeandds.com) 

    If you have questions about your healthcare plan or access to care, contact our Advocacy Team by calling 855-662-1029

    What "covered" should feel like.

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