Many patients are surprised that their dental insurance does not cover all of their expenses or that it doesn’t cover as much as they thought. Others think that if the dentist writes a letter emphasizing the need for treatment that they will get more benefits than the insurance company initially allowed. Most of these misconceptions come from a lack of understanding dental insurance.
Simply put, dental insurance is designed to help defray some of your dental expense. It is not intended to cover all your dental expenses. What insurance programs cover and do not cover is contractual and not based on what you may need or want in the way of dental treatment.
Dental coverage is structured differently from major medical coverage where the patient pays for a large portion of smaller expenses like office visits and medications while insurance pays for major costs like hospitalizations and surgeries. Dental coverage is usually highest for cleanings and exams and pays a lower percentage of major repairs. Benefits usually are capped at $1000 to $1500 per year. Dental plans may even require you to participate in the plan for a year or more before any of the more costly procedures are covered at all. Most dental plans exclude some dental procedures entirely.
The stated percentage insurance pays can either be a percent of the dentist’s fee or a percent of a dollar amount the insurance company sets, which is often unrealistically low. Since the insurance industry does not disclose how they arrive at a UCR amount there is no uniform coverage from insurance carrier to insurance carrier.
While many dental offices will try to estimate benefits to help you plan your obligations, it is at best an estimate. Since insurance may not cover as much as you would like, the best way to reduce out of pocket dental expenses is still through regular preventive visits and staying on top of needed maintenance.