Tips on Understanding Your Dental Insurance From a New York City Dentist

January 9, 2015 Updated: July 26, 2017

NEW YORK—The start of the New Year means new dental insurance plans for many people and I often find that patients misunderstand their coverage.

Most dental plans are provided by an employer and not available to individuals. There are several different types of dental insurance plans, and there is a lot of variation within the plan types.

Unlike medical insurance, there is minimal regulation of dental insurance in regards to what plans are required to provide. Here are some important facts I share with my patients at Gallery 57 Dental in New York City.

Limited Benefit, Not Insurance

Most people who think they have dental insurance really don’t—they have a benefit. There are a few plans that are closer to true insurance, and they are usually through workers’ unions.

This means that no matter what treatment you need, the most the insurance company will pay in a 12-month period is an annual maximum amount.

The annual dental benefit varies from $1,000 to $2,500 with $1,500 being the most common. This is fine if all you need are routine checkups, X-rays, and cleaning, but doesn’t help much if you have several teeth that need more work than a routine filling.

Plans Not Based on Need

Because these plans are a benefit and not insurance, they do not cover health-related needs, but rather they cover what the benefits manager has chosen.

Coverage usually includes routine cleanings, X-rays, and exams. Most plans then offer partial coverage for fillings and reduced coverage for major work. However, once the yearly benefit has been paid, they don’t cover anything.

Sometimes work can be postponed until the following year when a new benefit period starts, but often treatment should not be delayed that long, or the cost of it will exceed even the next year’s benefit. Patients must understand that unlike medical insurance, which covers most medically necessary procedures, dental benefits do not necessarily cover needed dental work.

Patients are responsible for co-pays and costs that exceed the yearly benefit, which can be substantial, so people who need a significant amount of work must budget for it.

Co-Pays and Deductibles

Co-pays are the portions of the bill that are not covered by the insurance plan and for which the patient is responsible. Here, too, there is a lot of variation between plans.

You should check your specific plan with your insurance provider or company’s human resources department to determine your co-pays and deductibles.

Typically there is no co-pay for hygiene, checkups, or X-rays. Fillings, root canals, and extractions usually have a 20 percent co-pay, and for major restorative work, the co-pay is usually 50 percent. It is illegal for the dentist to waive the co-pay, and the patient often is required to pay it up front.

The deductible also varies though often there is no deductible for routine hygiene and a small deductible for other procedures.

In Network Versus out of Network

Here, too, dental benefit plans differ significantly from medical insurance where there are often severe financial penalties for going out of network.

Most dental benefit plans pay up to a certain amount per procedure whether you are in or out of network, and there is often no penalty for going out of network. This means that you can choose the dentist you like without incurring significant financial penalty.

Dentists who are in-network agree to a fixed fee schedule while out-of-network dentists can set their own fees. However, unlike medical charges, which have a wide range, most dental fees are within a relatively narrow range, and often there is no or minimal additional charge to patients who chose out-of-network dentists.

For budget-conscious patients, going in network guarantees them the least out-of- pocket expense but restricts them to in-network providers. Going out of network, allows patients to choose the office they like best, often with minimal cost difference.

There are a minority of plans that are more restrictive if you go out of network, so you should make sure you understand your plan and benefits.

This article was sponsored by Gallery 57 Dental.

Gallery 57 Dental
24 W. 57th St., Suite 701
(Between 6th & 5th Avenues)