Many people wonder about the benefits of having dental insurance. But with so many options and clinical circumstances specific to each patient, you may wonder, is dental insurance worth it for me? This guide will tell you the highlights of what you need to know about dental insurance and dental insurance plans.
Dental Insurance: An Ounce of Prevention is Worth a Pound of Cure
‘All my life, I’ve been hearing about this ‘pound of cure.’ How much does it cost by the pound?’
Most dental insurance plans cover routine cleanings and checkups at no additional cost to the patient. Dental insurance clearly believes in preventative care. Dental issues can escalate very quickly, so everyone, ideally, should have preventative 6-month checkups. And prevention is not just about the mouth, according to the Oral Health Foundation, people who have lost 5 or more teeth by the age of 65 years are more likely to suffer from cardiovascular disease, diabetes, and osteoporosis.
Essentially, studies now show that poor oral health affects overall health, and dental insurance clearly gives merit to this concept. Therefore, dental insurance plans are great for routine general dentistry such as hygiene visits, exams, and minor restorative dental treatment each year.
Insurance Effectiveness Decreases with Complex Dentistry
The most common misconception about dental insurance is that plans cover 100% of treatment. Full coverage is usually not the case. Although preventative dentistry is covered at 100%, many restorative or surgical treatments are covered at only 50% to 80%. The remainder of the cost is required to be paid by the patient. Some treatments considered elective by many dental insurance plans such as porcelain veneers, and sedation dentistry may have no insurance coverage at all.
Patients who require significant reconstructive dentistry, a number of specialty dentistry treatments, or cosmetic procedures, may be better served by considering the following:
Pro tip 1: What procedures are covered by the insurance plan and at what percentage.
Pro tip 2: What is the yearly maximum benefit; weigh that against the cost of work your dentist anticipates.
Pro tip 3: The in-network provider list; make sure you are comfortable seeing one of the providers on that list.
Pro tip 4: Alternative options that can work with and without dental insurance.
The Advantages of Having Dental Insurance
The primary advantages of dental insurance are the preferred in-network adjustment and the percentage of coverage benefits.
The preferred in-network adjustment means that a patient receives discounted fees because the dentist has agreed to the negotiated rates. Be aware: The word “preferred” has nothing to do with the expertise of the dentist; it refers only to the fact that the dentist accepts negotiated fees with that particular insurance. Dental insurance can provide discounted fees from 10% off to 80% off when the patient sees an in-network provider.
The percent of coverage benefits means that insurance will pay a certain percentage of the cost of dental procedures up to the yearly maximum. For preventative treatment like exams or cleanings, the insurance may pay 100%. For complex restorative procedures, the insurance may contribute 50%. And for some cosmetic procedures that are considered elective, your dental insurance plan may not provide any benefit.
The Disadvantages of Dental Insurance
The primary disadvantages of dental insurance are the yearly maximum of benefits and the “network effect.”
Dental insurance is unlike medical insurance because it is capped at a yearly maximum, which is commonly $1,000 to $2,000 per year. After the maximum is reached, patients qualify for the negotiated in-network fees but must pay the fees in full themselves. When patients treat their work preventatively and only require a few treatments each year the insurance becomes most effective. When patients require a complete smile makeover or a full mouth reconstruction the dental insurance will only cover up to the maximum, even if the complex treatment costs several thousand more.
The “network effect” of dental insurance is also a disadvantage because many of the top providers and specialists are out-of-network. Patients may see providers who are out-of-network but they forfeit the in-network discounted rate which is a benefit they are paying for in their monthly insurance premium. The network effect sometimes can limit the quality of care if the patient requires complex dentistry, desires to be treated at a particular practice, or requires the expertise of a specialist who is out-of-network.
Consider the Alternatives of Dental Insurance
When thinking of assistance to help with the cost of dental treatment, insurance is probably what patients think of first. However, there are alternatives to dental insurance that can synergize with dental insurance plans or serve as a standalone option. Depending on your circumstances you should also consider utilizing a Health Savings Account, a Flex Savings Account, seeking a dentist that has an in-house discount plan, or using a dental financing company that can break payments over a period of several months such as the Lending Club or CareCredit.
Medical Insurance May Help
Dental insurance provides benefits for treatment that is considered dentally necessary, and medical insurance provides benefits for treatment medically necessary. So can medical insurance help cover dental treatment that is medically necessary? You bet it can.
But not so fast, before you start asking your dentist to bill you medical insurance for your next filling or crown, you need to understand, the primary cause has to be medically based. If the problem is due to only a tooth, it won’t be covered by medical insurance. Common dental conditions that may “crossover” to create medical necessity, and thus potentially have coverage by medical insurance are trauma from an accident, dental deterioration from a severe systemic medical condition or medication, TMJ dysfunction, removal of wisdom teeth, and sleep apnea.
Of course every situation is unique. If you have questions feel free to call us or visit our website for more information.
Charles Sutera DMD, FAGD is a nationally acclaimed dentist known for high profile smile makeovers, complex TMJ treatment, and IV sedation dentistry for the most dental phobic patients in the country.
He was one of the youngest dentists to achieve the FAGD award, a lifetime achievement award that only 6% of all dentists accomplish.
He is a patented developer of dental products used in the healthcare industry and serves as a dental legal adviser for law firms across the globe.
His practice, Aesthetic Smile Reconstruction, is located in the metro Boston area. The practice is known for a VIP experience and was the first to publicize the concept of cinema-style operatories for patient comfort.
Dr. Sutera has been featured in numerous national publications, radio, and TV appearances.