Insurance Information

Understanding Your Dental Insurance Benefits

Dental insurance can be a helpful resource for managing the cost of dental care. However, dental insurance works differently from medical insurance, and your benefits may not cover the full cost of treatment.

Every dental plan is different. Your coverage depends on the specific benefits, limits, fees, and terms included in your insurance policy.

Insurance May Not Pay 100% of Dental Procedures

Dental insurance is designed to help with the cost of dental care, but it does not necessarily pay the full fee for every procedure.

A plan may state that it covers 80%, 90%, or even 100% of a service. However, that percentage may be based on the insurance company's allowed or contracted fee, rather than our office's actual fee.

The amount your insurance plan pays may depend on:

• The benefits included in your specific plan
• The type of plan selected by you or your employer
• Your employer's agreement with the insurance company
• The insurance company's allowed or contracted fees
• Your annual deductible
• Your annual maximum
• The type of dental procedure being performed

Your insurance policy, not our dental office, determines your benefits and how much your insurance company will pay.

Your Insurance Plan Determines Your Benefits

Our office does not determine how much your insurance company reimburses for dental treatment.

Insurance companies may calculate benefits using their own fee schedules or allowed amounts. These amounts can vary significantly between plans, even when two plans are offered by the same insurance company.

For example, one employer's dental plan may cover 100% of a preventive service based on the plan's allowed fee, while another employer's plan through the same insurance company may cover only 50% of the allowed fee.

Because of this, a plan that states it covers 100% of preventive services does not always mean the insurance company will pay 100% of our office's actual fee.

We encourage families to review their dental insurance policy and become familiar with:

• Deductibles
• Annual maximums
• Coverage percentages
• Waiting periods
• Exclusions and limitations
• Allowed fees

If you have questions about the specific benefits included in your plan, your insurance company can provide the most accurate information.

Deductibles, Co-Payments & Allowed Fees

Several factors can affect your estimated out-of-pocket cost, including your deductible, your plan's coverage percentage, and the insurance company's allowed fee.

Example

For example, let's assume:

• Office fee: $150
• Insurance allowed fee: $150
• Annual deductible: $50
• Plan coverage: 80%

The first $50 would be applied toward the deductible, leaving $100 eligible for insurance coverage.

If the plan pays 80% of the remaining $100, the insurance company would pay approximately $80.

The estimated patient responsibility would then be:

$150 office fee - $80 insurance payment = $70 patient responsibility

This example is for illustration only. Your actual responsibility may be higher or lower depending on the details of your individual insurance plan.

If your insurance company's allowed fee is lower than our office fee, or your plan covers a smaller percentage of the procedure, the insurance payment may also be lower.

Pre-Treatment Estimates

When appropriate, our team is happy to submit a pre-treatment estimate to your insurance company.

A pre-treatment estimate can help you understand what your insurance plan may pay and what your estimated out-of-pocket responsibility may be before treatment begins.

To request an estimate, we need accurate and current insurance information. Please provide your updated insurance details as early as possible so our team has time to submit the necessary information.

Please keep in mind that a pre-treatment estimate is not a guarantee of payment.

Insurance companies may take several weeks to process an estimate, and the final amount paid can change based on factors such as:

• Your eligibility at the time of treatment
• Your remaining deductible
• Your remaining annual maximum
• Plan limitations or exclusions
• Changes to your insurance coverage
• Other claims processed before your treatment claim

Understanding Your Coverage Helps Avoid Surprises

Our team is happy to assist with insurance claims and provide estimates based on the information available to us. However, your insurance company ultimately determines your coverage and payment.

Because every dental insurance plan is different, we recommend contacting your insurance company directly if you have questions about your specific benefits.

Please remember: An insurance estimate is only an estimate and is not a guarantee of payment. The patient is ultimately responsible for any balance not paid by the insurance company.