How to Navigate Your Dental Insurance: Why Doesn’t it Cover Everything?
The health of your mouth and teeth play an important role in your overall health. Studies have found that there is a strong connection between your oral health and systemic diseases such as heart disease, diabetes, stroke and premature births
Your overall health is dependent on how healthy your teeth and gums are. Therefore, it’s important that you maintain your dental health with regular visits to your dentist. It’s best to look at your dental visits as an investment in your health rather than an expense. If you are lucky enough to have dental insurance, you may need some help figuring out how to maximize your coverage.
What is Dental Insurance?
Dental insurance is usually a policy that your employer has purchased for the entire organization. Sometimes policies can range in benefits within the organization. For example, a secretary at the school board may have different coverage than the principal. It’s important to recognize that the plan is an expense to your employer and therefore, they purchase your dental plan according to the affordability of it, not according to the dental services that will be best suited for your health. It’s best to look at it as a helping hand, and not as complete payment.
What does my Insurance Cover?
There are several parts of a dental plan. They are broken down into the following categories.
Basic: Diagnostic tests, hygiene visits, fillings, extractions
Major: Crowns, bridge, dentures, implants
Endo: Root canals
Perio: Gum surgery, periodontal therapy
Ortho: Invisalign, braces and/or orthodontic appliances
Often you will see coverage at a different percentage for each of these categories, usually ranging between 50%-100%. You will also see that there will be a total maximum amount your insurer will pay per year for these categories, either individually or all together. For example, a policy may pay a total of $2000 per calendar year per person. Once that amount is met, your insurance will not pay for any further dental services until a new calendar year starts. Policies may operate within a calendar year, school year, or revolving to the first date you used your plan.
It is also important to know that most dental offices in Ontario follow the ODA fee guide. This fee guide is updated yearly and will indicate changes in fees per service. Dental insurance is based off of this fee guide. However, your insurance policy may not pay to a current fee guide, and may pay to a fee guide for a previous year.
Why do I Have a Deductible?
A deductible is the amount your insurer will deduct from your payment at the first visit of your policy year. These usually range from $25 per person to $50 per family. When your plan is purchased from the insurer, this is negotiated within the plan to reduce the cost of it. You will be expected to pay the deductible amount out of pocket to your dental provider.
Why is There a Limit to How Often I can Have my Teeth Cleaned?
Frequencies to hygiene cleanings can be confusing. Hygiene cleanings are broken down into several categories:
Recall exams: This is when the dentist does a quick exam of your mouth and/or x-rays to look for cavities, bone loss, examine your periodontal condition, or broken down and worn out teeth. There is usually a limit on how often you can have an exam per year. The range is usually 6 months to 1 year.
Polishing: The hygienist uses pumice to polish your teeth and remove stains from eating, drinking, smoking or any medications. The limitations are usually the same as the recall exam of 6 months to a year.
X-rays: Nowadays, most x-rays are digital and have less radiation than you’d get from eating a banana, or getting on an airplane and flying to your favourite destination. X-rays are important to see what is going on inside the tooth and also to examine the bone level supporting your teeth; much like what blood tests do for the rest of your body. X-rays also have a frequency attached to them depending on the type of x-ray you have. Bitewing x-rays are typically once every 12-18 months, while a panorex or full-mouth set of x-rays are 3 to 5 years.
Fluoride: This is often the same as your polishing and exams.
Scaling units: This is the portion of the appointment where the hygienist removes the harmful bacteria in plaque and tartar from your teeth.
Usually, there is no limitation on scaling units per appointment when it comes to dental coverage, just a maximum amount you can use within your policy year. Each unit is considered 15 minutes of time, and most adults use anywhere between three and four per visit depending on the health of their mouth. Most plans have between 8 and 16 units of scaling. Some plans have unlimited, or you can ask for additional units if you require. This allows the patient to come in as needed to have their teeth cleaned to keep their gums, teeth and body healthy.
Make sure that you take the time to look through your dental insurance plan and benefits. Usually, your insurance company will send you a copy of your dental insurance plan and what it provides. Look over all of the numbers to make sure you are familiar with it, so you know what to look for when you receive a bill. Some offices will even offer a complimentary benefits check to help you navigate your plan.
The content contained in this blog is for informational purposes only, and you should contact your insurer for an exact breakdown of your insurance policy.