by Jeremy Granger
Most dental insurance plans can be broken down into three categories: Preventative, Basic, and Major services. Part I of this three part series covered Preventative Coverage and Part II will dissect Basic Services. Dental procedures that fall under the “Basic” category are subject to the plan’s deductible and yearly maximums. Within each category the following dental areas typically apply.
Typical dental insurance coverage falls into three categories:
- Preventative
- Cleanings
- X-rays
- Exams
- Fluoride
- Sealants
- Basic
- Fillings
- Endodontics
- Periodontics
- Oral Surgery
- Major
- Crowns
- Bridges
- Implants
- Dentures
What Procedures Fall Within Basic Dental Categories?
Services under this category tend to be procedures that are beyond routine maintenance and cavity prevention, but do not have a lab case associated with it. Examples of Basic Procedures include:
- Fillings
- Composite (White filling)
- Amalgam (Silver filling)
- Endodontics
- Root Canals
- Apicoectomies
- Pulpotomies
- Periodontics
- Scaling and root planing
- Gingival grafts
- Crown lengthening surgery
- Oral Surgery
- Simple extractions
- Surgical extractions
- Impacted bony extractions
- Wisdom tooth extractions
Not all services classified within an American Dental Association (ADA) Code or Dental Procedure (CDT) category such as endodontics will be covered under a plan's benefits.
What Does Basic Dental Coverage Cover?
Dental plans with “Basic” coverage usually reimburses either the patient or the dental office at 80% of the usual and customary fee or, for in-network dentists, the negotiated contract rate. Basic services are also commonly subject to a once-per-year deductible. Calculating a patient's coinsurance isn’t always straightforward and simple. Dental plans are often restricted by limitations and exclusions as well as yearly maximums. For instance, the American Dental Association’s (ADA) classification of Oral Surgery in the Code of Dental Procedures (CDT) ranges from D7000 - D7999. Having basic coverage that includes oral surgery doesn’t mean that every code between D7000 - D7999 will be covered at 80%. Many of them have no coverage at all and the patient must pay the fee.
How Do You Calculate The Patient And Insurance Portions Of A Dental Fee?
Calculating an insurance and patient portion of a dental fee that has a deductible applied is slightly counter-intuitive and uses the following formula:
Insurance Payment = (Procedure Fee - Deductible) x Coverage
Patient Payment = Procedure Fee - Insurance Portion
Example:
- Dental Fee = $200
- Deductible - $50
- Patient Portion = 20% of fee
- Insurance Portion - 80% of fee
- Insurance Payment = ($200 - $50) x 80% = $120
- Patient Payment = $80
Once the annual deductible has been met, estimating the patient and insurance portions is straight forward, assuming there are no limitations or exclusions on the dental procedure. For instance, if the plan covers fillings at 80% and the dental fee is $200, the estimated cost to the patient is $40 and the insurance payment would be $160.
Alternate Benefits And Downgrades
Another type of common limitation within a dental plan is an “Alternate Benefit”, often called a “Downgrade”, on posterior fillings. Most patients want composite, white fillings even on their molars. Many dental plans limit the amount they pay on posterior teeth further by paying 80% of silver amalgam and not the more expensive white fillings. For instance: if the fee for a posterior filling was $200 for silver amalgam and $250 for white composite, a dental plan may pay 80% of the $200 fee even if a white fill was placed. The patient would be responsible for 20% of the $200 plus the $50 difference between the two. This often leads to incorrect estimates and leftover balances. For instance: the dental provider may quote the patient $50 coinsurance based on 20% of $250, but with an “Alternate Benefit” the patient’s coinsurance is $90 leaving the patient with an excess $40 balance.
What Is A Pre-Treatment Estimate And Why Is It Important?
It can be very difficult to give a patient an accurate quote for dental care given the limited amount of information that is available when an insurance plan is verified. Many breakdowns of benefits are one page summaries of categories that leave out many of the plan’s limitations and exclusions. This can lead to minor or major miscalculation in estimated costs and reimbursem*nts. Sending a pre-treatment estimate to an insurance company takes anywhere from a few days to a few weeks, but is reviewed by the insurance company and returned with limitations, yearly maximums and exclusions applied if applicable. Although this route takes longer, it usually avoids surprise bills from the dental office.
To learn more about our practice visitBiltmore Avenue Family Dentistry's Home PageorContact USfor questions.If you enjoyed this article, we invite you to peruse our otherBlogsand check out our last article“UNDERSTANDING DENTAL INSURANCE - PART 1 (PREVENTATIVE)”.
