Personally, I think the word "insurance" is misleading when it comes to your dental plan. Most dental plans in the U.S. pay out very little. It is important for you to know how to navigate your own dental insurance plan to get the most out of it, and more importantly, avoid having a huge bill that you cannot pay for.
I am going to briefly walk you through a list of questions that you need answered about your dental insurance plan, and why you need to know this information. Attaining this information will probably be pretty easy if you either call into the helpline of the insurance provider, or use the insurance provider's website.
1. Do I have to use a dentist that is on a specific list?
This may seem like a ridiculous question, but it is very important. Sometimes, if you use a provider on a certain list, the fees will be more in your favor.
2. What happens if I use a dentist that is not on this list?
Using a dentist that is not on their list may not be as big a deal as you expect. They may say that you "have to" use a dentists from the list, but they might also say that it is not a requirement. They might tell you that a dentist outside of their network is fine, but you will be required to pay up front, and then submit for reimbursement. In fact, that is how mine works. I found out that I can see any dentist I choose, but if they are outside of the network, I will pay and submit for reimbursement. This has saved me a ton of money because, I have chosen to get my work done at the local dental school, and submit for reimbursement (more on this in next week's post).
3. What percentage does the insurance pay, and what percentage am I responsible for?
You could learn that your insurance company will pay out 80% of certain types of work, leaving you responsible for 20%. If your insurance works that way, you will want to know this. A dentist in my area charges $2750 for a ceramic crown. If you are responsible for 20% of it, that means you will pay $550. My insurance does not work this way, but I have had insurance in the past that did, and there were instances where my 20% created more of a bill than I was prepared for.
4. Is there a maximum annual payout? If so, what is it?
Many dental insurance plans will pay out a certain amount per calendar year. You need to know if this is the case. If your insurance plan has a maximum annual payout, it could be, say $1000. If you need more than just a filling or two, these funds can be eaten up very quickly. Remember the fee listed for the crown? This could wipe out your entire allotment for the year.
5. When does the "new year" start?
If your insurance company uses a maximum annual payout, you need to know how this "calendar year" runs. Is it January- December, or something else? Why is this important? If they will pay out $1000 per calendar year, and it runs January-December, than means a NEW $1000 starts in January. This is also a use it or lose it kind of system. That means that money does not roll over from one year to the next. For example, if you need a crown, and a couple of fillings, and it is November. You may want to get the crown done in November, which uses up your $1000 for the year. Then make an appointment for January (when your new money has come into play) to get the two fillings done. A dentist in my area charged $395 for a filling. If I only got a payout of $1000 per year on my insurance, and I tried to get the fillings and crown done in November, I could be left holding the bag on a lot of money. Using this example, it would be worthwhile to spread the work over a couple of months and take advantage of both calendar years.
When I investigated my own insurance plan, I found out that if I use a dentist on their network, the dentist bills them directly, and I pay only my portion. If I use a dentist outside of the network, I pay, then submit for reimbursement. My insurance does not have an annual maximum payout, nor does it operate using a percentage. They pay out using a fee schedule. So, I got a copy of that and learned that they pay $75 for fillings, etc.