How does dental insurance work?

Like medical insurance, dental insurance requires a monthly premium that you pay directly out of pocket or have deducted from your paycheck if you are on an employer-sponsored plan. Every plan’s coverage is different, but most plans have three categories with the 100-80-50 coverage amounts.

This means that plans often provide the following:

• 100% coverage for preventive care like cleanings, x-rays, and checkups for you and any dependents on the plan, and sealants and fluoride treatments for kids under 18.
• 80% coverage for basic dental care, which is considered non-surgical treatments like periodontal care, fillings for cavities, simple extractions, and sometimes root canals.
• 50% coverage for major dental services that involve lengthier treatments or oral surgery, which may include crowns, bridges, dental implants, complex extractions, and oral surgical procedures.

Some plans also provide coverage for orthodontic treatment, although expect to still pay a significant out-of-pocket amount even after insurance because orthodontic coverage is usually limited to a lifetime maximum per family member.

Keep in mind that insurance companies have contracted rates with dental offices. That means if we charge you $100 for a particular treatment and the insurance’s negotiated rate (which means the value they place on that treatment) is $80 and they cover that treatment at 50%, they pay half or $40 and you’re responsible for the other $40 the day of treatment. You won’t have to worry about knowing the contracted rates because we will provide you with those figures in your pretreatment estimate.

What does a deductible mean?

Some insurance plans have a deductible, which is a predetermined limit you must spend out of pocket before benefits or coinsurance kick in and cover any portion of your treatment. Deductible rules vary because some treatments require that you meet your deductible first, like getting a crown, while deductibles may or may not be required for preventive care.

What does a co-pay mean?

A co-pay or co-payment is a fixed amount that you pay as part of your service. In other words, it’s like paying a flat fee for your treatment or office visit. Co-pays are usually low-cost but can vary in cost, depending on the type of treatment and provider that you see. For instance, some plans may offer 100% coverage for preventive care, although require a co-payment at the time of your visit. You can determine if your plan requires co-payments by reviewing your plan details.

What’s the difference between in-network and out-of-network providers?

In-network providers are dentists that have agreed to accept a particular insurance plan. If a provider is out-of-network, you can still see that provider for care, but you’ll have a higher out-of-pocket cost as opposed to using an in-network provider. Your insurance company can provide you with a list of in-network providers upon request and sometimes that information is available on their website.

How does the insurance pay for my treatment?

We provide a treatment estimate before providing services. Keep in mind that treatment estimates are only estimates and the final out-of-pocket cost for you is dependent on what your insurance ultimately pays.

Once we devise your pretreatment estimate and you return for your first procedure, you’ll pay for your portion of the treatment for that day. Then, we bill your insurance, usually electronically, and will receive payment a few weeks later. Once we balance your account, we will bill you if for any reason the insurance did not cover the remaining portion.

What happens if my insurance does not cover my treatment?

At Quiet Valley Dental, we believe that patients should not let insurance dictate their care. In other words, we don’t recommend avoiding treatment just because your insurance isn’t willing to cover the cost or isn’t covering enough of the bill. There are instances in which dental insurance does not cover enough of the treatment for patients to afford care or perhaps doesn’t cover the treatment at all due to an exclusion. However, you can still choose to receive treatment as long as you’re able to pay for the cost. We believe that your oral health is intricately connected to your overall health, and while some treatments may seem expensive without insurance coverage, the repercussions far outweigh the cost today. Additionally, we also offer Care Credit, which allows interest-free monthly payments so that you can pay your bill upfront and make low-monthly payments later.

Family Dentists in Sciota, Pennsylvania

If you’re looking for trusted family dentists that offer a variety of services to suit your family’s oral health care needs, look no further than Quiet Valley Dental. Schedule a consultation today by calling (570) 992-7040.