The ABC’s of Dental Insurance
Dr Laurence A Langer, D.D.S.
HMO, PPO, UCR, Discount Plans, Freedom of Choice, PDO,..Confused yet? Welcome to the world of dental insurance. There are so many different types of plans, and each may have different coverage's, restrictions, maximums and deductibles. I love when a new patient calls, and tells me “I have a new plan, and they will pay up to two thousand dollars, so let’s get started on my crowns.” After we call to confirm the patient’s coverage, we inform her she has a co-payment of $500. The patient is irate, because her manager told her she has $2000 in coverage. However, what the patient failed to find out, is there is a deductible, and a50% co-payment based on the procedure. So, let’s take some time to get some of the confusion out of the way, and see how you can maximize your benefits and have minimal out- of pocket expenses. Below are some of the dental insurance plans that Dr. Laurence Langer, D.D.S. Cosmetic Dentist Brooklyn accepts at our Brooklyn Dental Office.
These type of plans are usual the most restrictive. You need to go to a participating dentist, or you might have to sign up with a specific dentist. Most times there is little to no payments required by the patient for most preventive care, and any other procedures are paid for by the patient at a “set” fee schedule by the company. You should have a copy of the fee allowances by the company. Keep in mind that the dentist receives no additional except their monthly capitation check, which is based on the number of patients that sign up for their office. You should be wary of these plans, and check for specialist availability which may be limited, and how readily you can be seen by the dentists you wish to sign on with.
These plans are less restrictive; however, you will need to go to a dentist who is “in-network”, in order to maximize your benefits. The insurance company sets the fees the dentist is allowed to charge. You usually have the option to go out of network, but may be subject to higher deductibles and co-payments.
FEE FOR SERVICE (Traditional plan)
These plans allow for freedom of choice…you can go to any dentist of your choosing, and you, or the dentist, will be reimbursed for each service based solely on the fees established by the dentist. Each plan has different deductibles, and co-payments, based on the type of procedure being done.
UCR (Usual, Customary, and Reasonable ) -Insurance companies determine these fees by region. Different methods are used to determine these fees. Some areas, such as Brooklyn, have a higher fee allowance.
LEAT (Least expensive alternate treatment) - this is when the insurance company determines that there is a less expensive option that they will pay for. It may not be in your best interest, but it is a viable option. For example, you would only like composite (tooth colored resin) to fill your teeth, and no silver or amalgam fillings. However, your insurance company will only pay for silver fillings, therefore you are left paying the difference in costs.
ANNUAL MAXIMUM - this is “total” dollar amount that your insurance company will pay each year. This does not necessary mean you will get all these monies, as each type of procedure is subject to co-payments. (See below)
CO-PAYMENTS - fees are usually broken down into 3 categories: preventive (exams, x-rays, cleanings), basic (fillings, extractions, periodontal treatment), and major (crowns, bridges, dentures). Each of these procedures are covered at a set percentage of the dentist/insurance company fees. Some or all are subject to your annual deductible. For example, you have 80% coverage for fillings. The fee for the filling is $100. Your annual deductible is $50. So, $100-50 is $50. 80% of $50 is $40. That is what your insurance company will pay. Your co-pay is the difference ($60).
DEDUCTIBLES- can range from 0-$250 or more. Every plan is different. It is paid only one time per calendar year, per family member.
MISSING TOOTH CLAUSE - your insurance company will not pay to replace any teeth that were missing prior to your coverage start date.
I hope this gives you some insight about your dental insurance. When you review a treatment plan with Dr. Langer at our Brooklyn Dental Office, we will tell you how you may be able to phase treatment, and maximize your benefits. We accept payment from most major insurance carriers, including Met Life, Aetna, Cigna, Principle, Americus, Delta Dental, Guardian, Blue Cross/Blue Shield, AIG, Dentamax, and many more. Call us for details.