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Which insurance is best?

This is a question I get a lot this time of year. I tell my callers there are a few items to consider and compare. I’d like to share them with you.

  • Monthly Premiums – How much does will your plan cost you each month?
  • Maximums & Deductibles – How much will your insurance pay out each year? How much is your deductible? Is your preventative treatment (cleaning, exam and x-rays) included in your maximum? Does your preventative treatment apply to your deductible?
  • Waiting Periods – Are there certain procedures that are subject to waiting periods? There may be a 6 month waiting period before the insurance will pay for a filling or 12 months for a crown.
  • Percentages / Co-pays – Does your plan pay based on a percentage? An average plan pays 100% preventative; 80% basic restorative; 50% major. Does your plan have co-pays? This would mean they work off a set fee schedule, paying a determined amount for each procedure and your copay is the balance.
  • Preventative / Basic / Major – What procedures fall under which category? Under some plans, x-rays or sealants are considered Preventative and paid at 100%. Some consider these procedures Basic and pay at 80%. Endodontics (Root Canals), Periodontics (deep scaling, gum disease) and Oral Surgery (extractions) can be considered Basic or Major, depending on your plan. For example, if a Root Canal falls under Basic and your insurance pays 80% of Basic then you only pay 20%. If they consider a Root Canal Major treatment and your insurance pays 50%, then you pay 50%. Your out-of-pocket may be less when it falls under Basic, however since the insurance pays out more, it uses more of your annual maximum.
  • Downgrades / Alternate Benefit – Does your plan downgrade for particular procedures such as composite (tooth colored) fillings or porcelain crowns? This means the insurance will pay their portion based on a less expensive material (silver). You pay your portion plus the difference in the cost.
  • Age Limits – Are there age limits on procedures such as space maintainers, fluoride treatments or orthodontics?

I had a patient come in and ask me about her dental plan. She told me she pays $85 per month out-of-pocket for her plan. I don’t know all the details of her benefits, but typically, based on the particular insurance company, is that she has a $1500 annual maximum & $100 annual deductible.  So she will pay out $1,120 to her insurance before they cover anything. If she comes in twice a year, her insurance will cover the 2 exams, 2 cleanings, and 1 set of x-rays. If she chooses to have fluoride, her insurance will not cover it since she is older than 18. Her insurance will pay out a total of $182 for the year. If she has 2 average size cavities and chooses to have them filled with composite rather than silver, the total fee is $236. The insurance will downgrade to silver fee which would be $174. After the $100 deductible, the insurance will pay 80% of $74 totaling $59.20. Our patient will pay $100 deductible plus $14.80 (20%) plus the difference between the composite and the silver which is $62.  So bottom line, the patient has now paid $176.80 of the $236 treatment.

Dr. Brough and I are of the same opinion that if you don’t have a lot of major treatment and your employer does not provide dental insurance, you would be better off to start a Health Savings Account or Flexible Spending Account. This will help you put money away and then pay cash at each dental visit. It is mistake to think that you cannot go to the dentist if you don’t have insurance. Maintaining good dental care at home, having a dental check up every 6 months, and taking care of dental needs while they are small will be your best insurance.

~Annette, Office Manager