Back to Patient Education

Dental Insurance Terms

Dental insurance provides wonderful benefits. However, there are numerous confusing provisions in the “fine print” of most contracts. Some common terms to know & understand:

• Deductible: How much you have to pay before your insurance begins to kick in. (Commonly $50-200). Some “categories” such as preventive services & exams may have no deductible, whereas other categories may have different amounts.
• Maximum: The most you can spend of your insurance company’s money each year. (Usually $1000-$1500)
• Categories: Carriers often present percentages based on 3 “categories” of services:

1. Diagnostic: Exams, X-rays, simple cleanings – usually covered at 80-100% of the insurer’s fabricated fee.
2. Basic: Fillings, Root canals- usually covered at 60-80% of the carrier’s assigned fee.
3. Major: Crowns, Bridges, Dentures, Gum treatment- usually covered at 0-50% of the artificial insurance fee.

• UCR Fees: The artificial fee your carrier assigns to each dental procedure. When your plan “says” it will pay 80% for a filling, it will pay 80% of this assigned fee, not what any dentist actually charges. There are virtually no regulations governing whether those fees are fair or realistic.
• Exclusions: Dental treatments that are not covered. Common examples include Dental Implants, various Cosmetic Services, certain Treatments for Gum Disease, & TMJ-Bite therapy. Over half of all the dental codes are excluded from most contracts.
• Alternative Benefits: If there are several ways to fix your dental problem, your carrier will pay for the least expensive option, even if you pick better care.
• Frequency Limitations: Coverage is commonly denied if your insurance paid for your procedure before. For example, your contract may indicate that your insurer will pay for the redo of a filling once every 7 years; or of a crown or denture every 10 years. Even if you need the treatment sooner, insurance may be exclude coverage.
• Pre-existing conditions: refer to dental problems that you had before your benefits became effective, where treatment may not be covered. A common example is denial to replace a tooth you lost before you had your dental insurance.
• Bundling: is when Insurance ignores specific treatment codes submitted by your dentist, gathers them as if they were a single treatment & pays on that only. A common example is various procedures bundled into one for Oral or Periodontal Surgery.
• Medical Necessity: is when your contract specifies that treatment is not covered for a specific problem, whether it is needed or desired. A common example is for a root canal on molar teeth or Gum Procedures.
• Better Plans: Your neighbor may have the identical problem you have, but a better insurance plan. A different insurance company or even the same carrier may pay the neighbor more if his/her contract assigns a higher fee, fewer exclusions etc.
• Need Verses Contract: Your dental coverage is based solely on the legal language in your contract; not your health needs. The more your employer paid for coverage, or the higher your premiums the better your plan will be.

Common Questions About Dental Insurance

1. How does dental insurance work?
Dental Insurance will help pay for SOME of your dental needs. The more your employer paid for coverage, the better your plan will be. Whatever your benefits, they are a wonderful gift to have.

2. How are plans different?
Most plans have co-payments, deductibles, maximums, and excluded services. Please refer to our “Dental Insurance Terms” section, for explanations & examples of these confusing features.

3. Can Dentists waive my portion & accept whatever insurance pays?
This seems innocent enough, but it is actually illegal for your dentist to do so, as it is considered falsified billing. Carriers audit records for such activity and prosecute violators.

4. Can you change codes, or dates, to get me better coverage?
No, this is fraud. Insurance carriers can inspect records, x-rays, lab slips & other records. You and your dentist can be fined or imprisoned.

5. I reached my maximum in no-time. Is that normal?
The common $1000-$1500 maximum was set 50 years ago as a “reasonable” level of dental coverage per year & has not increased since. Many people need care that far exceeds this artificial maximum.

6. If I don’t have coverage, it must not be necessary; right?
No. Your insurance contract is designed by lawyers and financial experts to control costs, so that the limitations of your policy have no relation to the treatment that you need or want. Your dentist’s responsibility is to advise you what treatments are available and what is best for you.