Some Dental Insurance Basics

Dental Insurance

Dental Insurance Plans are different than Medical Insurance

The staff of WNC Dental have over 25 years of dental insurance experience and we want to give you the very best information we can get on your dental insurance plan. However, there are 100s of plans so sometimes it takes some real research to get answers about your particular flavor of plan.

Among the many plans we work with:
Delta Dental
and many more...

We do believe every patient should know some basic facts about dental insurance.

  •     Dental Insurance is not at all like Medical Insurance.
  •     Unlike some medical plans, dental insurance never covers everything.
  •     Unlike medical insurance, dental insurance has a low maximum benefit per year.
  •     The Standard fees at WNC Dental are generally lower than national averages.
  •     In addition, WNC Dental has contracted with many dental plans to accept even lower than our Standard Fee. Your insurance company calls these reduced and discounted fees “UCR, Covered, or Allowed” fees and believe it or not, they are often based on the dental practice zip code.
  •     Because of this, we must collect deductibles and co-payments at the time of service.
  •     Dental Insurance comes in thousands of variations. Even with the same company, there may be many variations of your particular plan that your employer has decided to cover. This is why we can never give an EXACT estimate of your costs or our payments.
  •     ALL dental insurance coverages are ESTIMATES at all times until the actual payment is received.
  •     Dental Insurance plans will often only pay for cheaper materials like mercury silver amalgam instead of white acrylic resins (composites). If your plan “downgrades” your back fillings to amalgam where we recommend modern composites, you will be responsible for the modest difference in cost.
  •     We will make every effort to Pre-Authorize any treatment plan over $250 to help you and us understand the ESTMATED amount your plan might cover. However, even these estimates may differ from the actual payments.
  •     Dental Insurance is a contribution toward your dental health and not a full coverage of your dental health. We want you to receive as much benefit as you can from your plan and all we ask is that you do not let your insurance company make health care decisions for you.

Dental Insurance

Different Types of Dental Insurance Plans

Types of Dental Insurance

Dental Indemnity or Fee for Service Dental Plan
For a monthly premium, the Dental Insurance Company will pay for a part of  the cost of your dental treatment and you will be billed for the balance of  the dental office’s normal fee. You can go to any dentist that accepts this type of insurance and the dentists do not have to be approved  providers by the Insurance Company.

Dental Preferred Provider Plans (PPO)

Dentists who accept PPO Dental Insurance have to become an “approved provider” by the Insurance Company and have to agree to discount the regular normal office fees.

How Dental Insurance Works

MOST IMPORTANT: Dental decisions regarding your treatment should always be between the patient and the doctor. The patient should always hear all the options for their best treatment first, before considering what they can afford financially. In addition, dental treatment can often  be done in phases that allow completing dental treatments more affordably over a longer period of time.

Dental Insurance is a contract between the patient and the Dental Insurance Company.

Many dentists will “accept assignment of  benefits” which means that they agree to do most all of the paperwork involved with dental insurance claims and receive the Dental Insurance Company portion of payment directly to the practice. Other dentists may require you to pay in full at the time of service and just give you a receipt and you have to do all the paperwork yourself for the dental insurance claim.

Dental Insurance helps pay for PART of the cost of dental treatment.

The Dental Insurance Company first decides what dental services they will cover and then they decide what they think the fee for each service ought to be, often based on your zip code, believe it or not.  (Yes, dentists in New York can get paid more than dentists in North Carolina)! The Dental Insurance Company calls their fees “UCR” fees which stand for “Usual Customary, and Reasonable”. This makes their determination of fees sound very fair but in reality it has nothing to do with the actual cost of delivering the dental care. In fact, different Dental Insurance Companies vary wildly on what they say the UCR fee should be for the exact same service. One company may say the fee for a dental cleaning should be $70, another company say the UCR should be $85 and a third company may say the fee should be $50. Needless to say, this can be very frustrating for both the dentist and patient in trying to estimate the final cost to the patient for each dental procedure they need.

Dental Plan Language

Deductible- many plans require the patient to pay a small amount toward their treatment before the Dental Insurance Company will begin paying the dentist.
Pays 100% of Cleanings and Checkups- means they will reimburse up to their UCR fee. If you have a traditional indemnity fee for service plan, you may still owe a balance if the “UCR” fee is less than the normal office fee, even if the company says it covered  “100%”

Example: Normal office fee- $80

Dental Insurance UCR- $70
Patient pays balance of  $10

In PPO plans (most of WNC Dental) we have agreed to discount our normal fees and accept whatever the Dental PPO Insurance Company says is the “maximum allowable” fee for each service.
Also, the more expensive the dental treatment, the less the Insurance Company will cover so you may often see language like:
“80% of restorative” (fillings), “50% of crowns” (caps) etc so we talk about services covered at 100%,80%,50%, etc
100% covered PPO Example: Normal Office Fee $80
PPO max allowed discount Fee $60
WNC Dental accepts $60 as full payment and pt owes no balance.

80% covered PPO example: Normal Office Fee 2  surface front filling  $170
PPO max allowed discount fee  $132
Insurance pays 80% of 132 = $105.60
Patient owes balance of  132.00-105.60 = $26.40

50% covered PPO example: Normal Office fee full porcelain crown $985
PPO max allowed discount fee $758
Insurance pays 50% of 758 = $379
Patient owes the other 50% balance of $379

Dental Insurance Company Yearly Limitations

Dental Insurance Companies usually have a yearly dollar limit that a patient can use. Typically it is $1,000 to $1500 per year and these limits have not significantly changed in the past 40 years! Dental Insurance Companies are for-profit businesses and must collect more in premiums than they pay out in claims.
The dentists at WNC Dental want you to receive the most benefit from your dental plan and will try our best to give you the closest ESTIMATE of your share of your dental treatment costs. Dental Insurance Companies change their benefits all the time and each employer may have a variation of the same Company’s dental plan so it is near impossible to give exact numbers in working with dental insurance but we’ll sure try! All we ask is that for these discounts and paperwork, you the patient take care of your balance in a timely fashion.