Decoding Dental Insurance

Decoding Dental Insurance

Dental insurance can feel like a mysterious and difficult concept to crack. Unless you have experience in the dental field or have spent time studying the subject, you may feel at a loss when shopping for dental insurance, or understanding the plan you currently have.

Fortunately, our Patient Care Coordinators (PCCs) act as translators and navigators for the vague world of dental insurance. You’ll know our PCCs, because they’re the first to greet you when you walk in to Timber Dental, and they complete your check-out right before you leave. In fact, because they work with doctors, patients, and dental insurance companies, they act as the arteries of the practice by connecting everything together. With a cumulative background of 32 years in the industry, our PCCs are an excellent resource—a resource you’re invited to tap into!

Here are some common dental insurance terms to get you started.

Maximum

Your maximum benefit is the limit of what your insurance company will pay out towards dental procedures. After you’ve reached your maximum, any subsequent procedures for the remainder of your benefit period will be charged out-of-pocket at full price.

The National Association of Dental Plans (NADP) indicates that the average PPO plan has a maximum benefit of $1,000-$1,500. Not-so-fun fact? Dental insurance maximum averages haven’t increased since the late 1970s. If they had kept up with inflation rates, maximums would be something more like $4,000-$5,000!

Benefit Period

Your benefit period is the span of time your policy covers before either ending or being renewed. When your benefit period restarts, your maximum benefit is replenished. Many benefit periods follow the Calendar year—January 1st to December 31st of any given year. However, some benefit periods start at a different time and span the next 12 months: this is called a benefit year, or BY for short.

Deductible

Your deductible is the amount you must pay once every benefit period (per subscriber) before your dental insurance kicks in. For most policies, preventative procedures like x-rays and cleanings don’t require the payment of a deductible; it only applies once you have a more advanced procedure, such as a filling or crown.

Frequency

Policies carry certain criteria that must be met in order for procedures to be covered. The most common criteria is that of frequency, or how often you’ve had a dental precedure. It’s a good idea to inquire about frequency limitations when shopping for dental plans, especially if you’re someone who requires extra cleanings due to a history of Periodontal Disease. Otherwise, you may be paying out-of-pocket for those extra cleanings!

Preventative, Basic, and Major Services

All dental procedures are divided into three classes: Preventative, Basic, and Major. Preventative is pretty much like it sounds: x-rays, cleanings, and periodic exams are all procedures intended to prevent or delay decay. Usually, Preventative procedures are covered at the highest percentage: 80-100% is pretty common. Basic Procedures, also called Class II, are a step up from preventative. These usually include fillings, oral surgery, and emergency care for pain relief (palliative), and are covered at a smaller percentage, such as 60-80%. Finally, major services, also called Class III, are the most extensive dental procedures, such as crowns, implants, and partial dentures. Major services are often covered at 40-60%. Let this motivate you to keep up on your preventative services: this could potentially delay or avoid more expensive procedures!


Remember, if you ever have questions about your policy, our PCCs are here to help! Just give us a call at (503) 765-7355, or feel free to bring up any questions / concerns you may have when you check in or out of your appointment.