Dr David Chen's Guide for dental PPO insurances
This is the guide for understanding dental insurances for dummies. There will be examples explaining how deductibles and copays are determined. Let us enlighten you.
Why is dental insurance so bad?
Dental insurance is fundamentally different from Medical insurance because it works on a punishment based system.
When you come regularly for your dental check ups, xrays, and cleanings…
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Your insurance will typically reward you with 100% coverage of the visit.
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(99% true but there are exceptions)
As soon as you encounter a problem such as needing a filling either because a) you did not come regularly or b) you’ve been naughty with your brushing/flossing routine while consuming excessive quantities of sugar...
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Your insurance will typically punish you and drop your coverage for whatever procedure it is that you need down to 80%
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(80% is the most common coverage percentage for say a composite filling but it may differ depending on your specific plan)
If you have a small problem but you choose to ignore it and let the small problem become a big problem such as a small cavity becoming a root canal or a crown…
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Your insurance will typically punish you and drop your coverage down to 50%
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(50% is the most common but it may differ depending on your specific plan)
If you decide to test the limits and explore uncharted territory by going where no man has gone before by letting the problem fester into a catastrophic one, thus needing full mouth reconstruction...
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Expect zero coverage
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(100% true and there are no exceptions)
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Most plans have a deductible that will activate as soon as you need treatment. The deductible must be paid before any benefits can be applied.
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The deductible is typically $50 for each year. That means if you paid the deductible on Dec 31st and come back on Jan 1st, you will need to pay the deductible again.
Last but not least, the deductible amount and coverage % for each of the procedures will vary depending on your insurance plan but if you are ever wondering why it is that specific number… it is because your HR negotiated for that. They could negotiate for 100% if they wanted to.
The above holds true for the vast majority of plans that we’ve seen but there are some even more interesting ones out there that don’t seem to follow any rules... Just an observation by our long island city dentists.
Let's review some insurance Terminology
Annual Maximum
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The max amount of dental benefits in dollar amounts that your insurance will contribute to your oral health care.
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Annual Deductible
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The amount that you have to pay before any insurance benefits take into effect. This amount is refreshed every year, meaning it needs to be re-satisfied each plan year.
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Copay or coinsurance
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Your dental insurance will cover however much they agreed upon and whatever that is left or not covered will be your responsibility. The amount that you are responsible for is commonly known as copay. You basically pay the difference between what the insurance does not cover.
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Alternative Benefit
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Essentially when your insurance downgrades your procedure to a less costly option because they deem it as sufficient. Unfortunately you are responsible for the difference in the downgrade.
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A common example would be receiving the white tooth colored composite fillings. There are some insurances out there that will apply an alternative benefit of an amalgam filling, which is a silver filling in place of the composite one. This is so that the insurance can reimburse less of the visit but you will be responsible for a greater portion due to that.
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Another alternative benefit example would be giving you a metal crown tooth instead of an all porcelain crown. Do you know the disadvantages to a metal porcelain crown?
Now let's dive into some MATH about teeth!
(The numbers are just for example purposes!)
Scenario #1
Cigna DPPO insurance
You have a cavity and our LIC dentist gives you a composite tooth colored filling.
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You have a $50 annual deductible
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Your insurance will cover 80% of the procedure
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The composite filling price is contracted by your as $200 total.
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What is your total copay for today's friendly visit to the dentist?
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Your copay = (200 - 50) * 20% + 50 = $80
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Please be aware of a couple of key points:
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The deductible comes off first
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Don't forget to add the deductible back in!
Scenario #2
Metlife PDP or PDP Plus insurance
You are returning for a second cavity and our long island city dentist gives you yet a white cavity filling.
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You have a $50 annual deductible
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Your insurance will cover 80% of the procedure
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$200 is the composite filling price set by your insurance
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What is your total copay for today's friendly visit to the dentist?
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Your copay = 200 * 20% = $40
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Please be aware of a couple of key points:
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You already paid for the deductible so you are only responsible for the copay today!
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If you returned to the office the year afterwards, your insurance would reset and the deductible would kick in again!
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If you switched insurances in between visits, the deductible would be refreshed as well.
Scenario #3
United Healthcare PPO insurance
You have a cavity and you demand a tooth colored filling because the silver fillings are messing with your mojo.
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You have a $50 annual deductible
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Your insurance will cover 80% of the procedure but they have an alternative benefit of amalgam.
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The contracted insurance fee is $200 total for the white filling
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The contracted insurance fee is $150 for the silver filling
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What is your total copay for today's dental visit?
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Your copay = [(150 - 50) * 20% + 50] + (200 - 150) = $120
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Please be aware of a couple of key points:
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It is similar to scenario #1 but you have to add in the difference between the alternative benefit!
Scenario #4
Guardian dental insurance
You drink eight cups of coffee a day and you have brown stains on your teeth. You would like some stained teeth treatment such as professional whitening.
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What will be your copay for today?
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Unfortunately the copay is irrelevant because we have yet to see a single dental insurance cover a cosmetic benefit such as whitening. It does not matter if you have guardian, cigna, delta dental, or whatever.
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You will be responsible for the full fee!
Frequently Asked Questions
So, what exactly happens when there is an alternative benefit?
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Basically when an alternate benefit is applied, it is because your insurance thinks that you should be sufficient with a different procedure, often a lower reimbursing procedure. They will apply the benefit for the lower procedure but you will be responsible for the difference. Essentially, the insurance is passing the cost onto you. They are covering less of the procedure than they otherwise should be.
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What happens if I max out my insurance?
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If you max out your insurance you can still receive your dental care. It is just that your insurance will not reimburse any portion of the visit so you will be responsible for the full cost. A lot of patients are under the impression that once they are maxed out, they can't come back.
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Although we do advise that you should try to take full advantage of your insurance maximum.
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Where is the list of insurances again?
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Please click HERE for the list.
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If your insurance is just bad and nothing is covered, are there alternative ways to pay for treatment?
You can use care credit for dental, which offers flexible financing options including 24 months interest free plans.