| Is dental insurance a good
thing?
Yes! Insurance has helped
millions to achieve a higher
level of dental health. But
it must be used correctly.
Some people believe that if
they don’t have insurance
that they can’t afford
dental work. Some people with
insurance believe that if
their insurance won’t
pay for dental procedures,
then they must not need it,
or they believe it isn’t
important. Others won’t
spend beyond its limitations.
THE TRUTH is that dental insurance
provides help with getting
dental work you would do anyway
(you just budget differently).
Not having insurance doesn’t
make your teeth less important
or necessary for health, social/career
success, or self-confidence.
Besides, you only get a limited
amount of coverage anyway!
Dental insurance is a good
thing if you don’t let
the insurance company make
your health decisions for
you, or think that without
it you can’t afford
dental care.
What is dental insurance?
Insurance is a way of controlling
risk and protecting yourself
against a financial loss by
spreading the risk of loss
across a large population.
Common examples include auto,
home and life insurance. Premium
rates and costs are determined
by adding up the calculated
costs of benefits paid out,
plus overhead and administrative
costs, plus the profits desired
by the insurance company.
Like any other insurance,
better benefits are obtained
by paying higher premiums.
What will my dental
insurance cover?
Unlike major medical, there
is no such thing as “major
dental”. Few, if any
dental insurance plans are
a “pay-all”. Some
insurance companies pay a
fixed amount, others a percentage
of pre-determined limits.
Any plans that claim to or
actually do pay the entire
dental bill can only do so
because of agreements or choices
that discount services, or
offer low quality or cheaper
treatment.
What dental services
are covered? What aren’t?
Like any other insurance,
your insurance coverage is
only as good as the policy
that was purchased. Many people
are surprised to discover
that many dental services
are not covered. If you are
dissatisfied with the amount
or limits of your coverage
it is important to discuss
this with your employer and
insurance company.
In an attempt to decrease
their costs, dental insurance
companies tend to reward prevention
and limit reimbursement for
complex or more involved care.
In short, while they may pay
well for wellness checkups
and cleanings, they tend to
discourage higher quality
services. Higher quality and
“major” treatment
services may not be covered
as well, or at all. The coverage
available to you is solely
determined by the profit structures
of the insurance company and
the quality of insurance purchased
by you or your employer. Better
insurance coverage costs more!
Why won’t my
insurance pay more?
Unlike major medical plans
which may cover complex treatment
and protect against “catastrophic
loss”, all dental plans
have a “stop-loss”
or “Annual Maximum”
which typically ranges from
$1,000 to $1,500 per year.
This means that regardless
of your need or situation,
the insurance company will
not pay out more to you than
this annual limit. Thus there
is no risk or downside to
the insurance company, and
it hardens or stabilizes their
profits. For you, “dental
insurance” equates to
nothing more than having “pre-paid
dentistry” which you
must use or lose each year.
Additionally, complex and
convoluted rules and formulations
for payment of benefits are
created and used by your insurance
company to deny, delay, and
defray the reimbursement of
covered services.
Do insurance companies exist
to pay for dental care?
There is only one purpose
for dental insurance companies
– to make a profit.
Ironically, while insurance
premiums have steadily increased
over the past 35 years, the
average insurance coverage
is still the same as it was
35 years ago when it started
- $1000. Inflation alone should
certainly have increased the
available benefit to over
$5,000-10,000 today. Your
insurance company gives you
increasingly less coverage
and charges you more for it.
It is why they can pay their
CEOs extraordinary salaries
and continue to own and acquire
real estate and stock market
holdings as they do. (Why
would they want you to get
cheaper dentistry, or deny
payment for quality care?)
How does my insurance
company make money?
Income minus overhead equals
profits! In other words -
Your insurance company collects
the premiums, administrates
the benefits plan, and makes
a profit on the difference.
Complex rules for annual limits
(“stop-loss” maximums),
utilization of services, coverage
percentages, and UCR fee schedules,
aid the insurance company
in their quest to take in
more money and give out less
in the way of benefits. They
are typically very slow to
adopt modern treatments, they
disallow alternative based
therapies, they usually disallow
coverage for functional based
problems and they cover other
high quality procedures poorly,
and they use their own internal
fee schedules (U.C.R. dictated
by zip code geography) that
are not the same as your dentist’s
fee schedule, and which is
determined solely on the profit
motives of their company.
“Deny, delay, and defer”
are watch-words that infamously
characterize the insurance
industry and frustrate both
doctor and patient in trying
to be made whole after care
is rendered. Pre-authorization
and pre-determination rules
complicate and hinder the
timely and effective delivery
of care – all unnecessary
and designed to delay and
second-guess the doctor-patient
relationship and increase
the profits of the insurance
company. We are all grateful
for what insurance can and
does afford us. All insurance
companies are contractually
obligated to pay benefits
to which you, their insured,
are entitled. The “game”
lies in getting there.
Who is responsible for payment?
When you present for care
and agree to treatment, you
accept direct responsibility
for paying the dental bill
to the dentist, regardless
of third-party coverage or
assignment of benefits. Remember
that your dentist works for
you, not your insurance company.
Our staff will assist you
in filing insurance claim
forms, but we can’t
guarantee any estimated coverage.
What should I do if
I don’t have insurance,
or run out of insurance coverage?
Approximately 60% of our population
does not have dental insurance
coverage. When it comes to
their own dental needs, they
simply budget their discretionary
dollars so as to afford dental
care. If needed care exceeds
your insurance coverage (a
very likely scenario) you
will do the same.
It is more about what you
value than the amount of money
available. Proof exists in
the fact that we buy cars
or boats, go on vacations
and travel, buy pet food,
cosmetics and hair care, do
recreation and dinner out
(and not always at the cheapest
restaurant), tobacco, alcohol,
etc. – in essence, have
a lifestyle – all without
using insurance reimbursement
to fund it. The truth is that
little if any of this “lifestyle”
spending is “necessary!”
It is all discretionary! Unlike
heart attacks and broken legs,
almost all of dentistry is
discretionary as well. (How
many broken smiles have you
seen lately?) The key is to
understand and change your
values, to make better discretionary
spending choices, and to make
it affordable with financial
options - before you suffer
irreparable damage.
Should I use my insurance
coverage to determine my dental
treatment?
In a word – “No!”
It is understandable that
you might want to make treatment
decisions based on how much
coverage you have. You may
even assume that your coverage
will pay for all of your costs.
Regrettably, this is not the
case! Just as you would never
choose to leave portions of
your cancer untreated, you
shouldn’t choose to
ignore dental decay, broken
teeth, toothaches, abscessed
teeth, and maybe even unattractive
unflattering smiles that hurt
you socially or in your career.
This would be true whether
you had or didn’t have
third-party coverage, or had
limitations of coverage therein.
Your insurance company doesn’t
care if you have disease or
ugly! Their primary interest
is not you. It is in protecting
the difference between their
income and their outgo. Period!
What does it mean
when my insurance company
tells me my dentist’s
fees “exceed usual,
customary and reasonable”?
What is “UCR”?
It usually means that your
insurance benefits are too
low. Better insurance plans
will often pay a higher amount.
With dental insurance, you
get what you and your employer
pay for minus the overhead
and profits of the insurance
company.
“UCR” stands for
Usual Customary and Reasonable.
The insurance industry uses
this term to try to standardize
fees and to make a commodity
out of professional services.
They would have you believe
that a dentist is a dentist
is a dentist, and a crown
is a crown is a crown, regardless
of the training, care, skill
and judgment required to accomplish
it. There is no UCR fee that
truly represents “usual,
customary or reasonable”
that isn’t created internally
by the insurance company based
upon its own internal overhead
and profit calculations.
Will my dental insurance pay
for my dental care?
Yes – up to a point.
And that point is determined
by the limitations and exclusions
in your insurance policy,
and the type of plan it is.
Why does my insurance company
not pay for some procedures?
The determination of whether
certain procedures are covered
or not is dependant on what
type of policy and how much
your employer pays for it.
Typically, insurance will
not pay for “elective”
or “functional”
problems that do not have
their basis in trauma or pathology.
Some modern dentistry and
newer cosmetic procedures
are likewise not covered.
The purpose of dental insurance
is not to be a pay-all or
make you look beautiful, but
to help defray the expenses
associated with prevention
and minor reparative work.
What is the relationship
between dental fees and insurance
coverage?
When an insurance company
policy states it will pay
X % of a procedure, it is
using its own fee schedule,
not the dentists. Usually
insurance companies fee schedules
are lower than the dentists.
These fee schedules are internal
to the insurance company,
are determined solely by the
overhead and profit motives
of the insurance company,
and have no relationship with
the actual fees charged by
the dentist. Additionally,
these fee schedules will vary
from area to area, despite
the uniformity of the standard-of-care
in our country. Insurance
companies would have you believe
that you can get something
for nothing.
What’s the best
way to deal with problems
related to my dental health
benefits?
You are best advised to discuss
issues that may arise with
your employer or his human
resources manager, and/or
your labor union. Remember
that the “richness”
of your benefits package is
determined by how much is
paid for the insurance policy
in the first place, as well
as the internal policy rules
that regulate the ease and
availability of getting the
benefits paid out.
What are the different
kinds of insurance plans?
There are three main types
of insurance:
1. Traditional indemnity
insurance plans
2. Preferred provider organizations
(PPO)
3. Health maintenance organizations
(HMO)
Traditional indemnity plans
offer the greatest freedom
of choice in services and
health care providers. PPOs
and HMOs, sometimes referred
to as “alphabet”
and “managed care”
plans, frequently result in
less freedom of choice for
the patient , fewer available
appointments, cheaper dental
materials and lab quality,
and have more restrictions
and exclusions in what they
cover.
Do I have to go where my insurance
company says? Am I required
to see a certain dentist?
No! But if you have a closed
or restricted plan, you may
not receive the meager benefits
purchased unless you see their
preferred doctors who have
agreed to discount their services
and who offer cheaper care.
If you have one of these plans
and if you decide you want
better care for yourself or
your family than what your
insurance policy will pay
for, you are always free to
choose higher levels of services
and higher quality of care
from private fee-for-service
offices such as The Center
For Dental Health. Traditional
indemnity insurance plans
are representative of the
better plans and do not have
prohibitions or restrictions
on who you may or may not
see.
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