Trying to make sense of your dental insurance?

Now, here’s the 411 on dental insurance…

Group Vs. Individual

Group policies are typically offered through an employer. Individual policies are purchased by an individual through the open marketplace. The information given on this website refers mostly to group policies. Individual policies vary greatly, and for this reason can be difficult to find commonalities or make any assumptions regarding coverage. Some individual policies have extremely low fee schedules, low allowable amounts and low maximums when compared to most group polices. We encourage you to read the fine print before purchasing an individual policy. Remember, you don’t have to have dental insurance. In fact, A Cook Club Membership may save you money if you don’t have dental insurance through an employer.

Out-Of-Network Vs. In-Network

There are three types of providers: In-Network, Out-Of-Network, and Fee For Service. (Cook Dentistry is considered Out-Of-Network w/ the exception of Delta Premier.)

In-Network. An insurance company will petition dentists to join their network with the promise of an increase in volume of patients. Then some insurance companies will negotiate with the provider to determine rates for services that they deem reasonable and customary. Some insurance companies will not negotiate these rates. An In-Network dentist is required to adjust off the difference between their charge and the allowable amount set by the insurance company, so that the patient is only responsible for their portion up to the allowable amount. Sounds great, right? Maybe, Until you really think about an insurance company’s motives. Insurance companies are only profitable when they collect more in premiums than they pay out in claims. What if your employer changes their plan, and you now need to find a new provider because yours isn’t in the new plan’s network? What if your dentist isn’t available when you have an emergency because he/she has to see a higher volume of patients to cover the cost of the adjustments for the patients who have those policies with dramatically low fee schedules?

Out-Of-Network. At Cook Dentistry, we think there’s a better way. Dr. Ryan Cook is decidedly an out-of-network provider for most dental insurance companies. Visiting an out-of-network dentist does NOT necessarily mean that insurance will pay less and you will pay more. What it does mean, is that Dr. Cook is not beholden to an insurance company. Dr. Cook can recommend treatment and services based on what is best for you, the patient, regardless of what an insurance company says is okay. We set our fees based on market research with the intention of remaining competitive while using superior products, excellent labs, and the latest technology. We don’t feel an insurance company is looking out for your best interests when they reduce benefits or penalize you for choosing a provider outside their network. Thankfully, most don’t do this. We estimate what your out-of-pocket amount will be, and ask you to pay the estimated amount at the time services are rendered. If insurance pays less than we estimated, we will bill for the remaining balance. If they pay more, we will promptly refund the overage or apply it to your next visit per your request.

Fee For Service. Fee for service providers require payment up front. The provider will file your insurance to reimburse you for services. We are NOT a Fee For Service provider and do accept assignment of benefits from most insurance companies.

No Two Policies are alike

There are literally thousands of insurance policies, and each on is different. Just because you have Blue Cross Blue Shield, don’t assume it’s the same as your friend’s BCBS policy who works somewhere else. The same goes for all the big names: Cigna, Delta, BCBS, Aetna, MetLife, Lincoln, Principal, United Healthcare, etc. Each one of these companies negotiate and sell dental insurance polices to many different employers or groups. Some employers even offer different tiers of coverage to their employees. Depending on which tier of coverage you choose, your policy may be different than your coworker even though the dental insurance company is the same and you share the same employer. For example, Prisma currently offers a high option Delta plan and a low option Delta plan. Both are administered through Delta, but they are very different policies, with different maximums and percentages covered. Also, Even though the name of the insurance company may be the same, the claims filing address and other pertinent info may be different. For example, it’s not enough to call and say that you have Delta. There are many different Delta’s each with their own claim filing address, customer service phone numbers, and electronic payer id’s. We need to know which “Delta,” and this information is usually found on your dental insurance card which may not be the same as your medical card.

The Breakdown of Benefits

Most of the time we can do an eligibility check and provide you a breakdown of benefits. Provided, of course, that you bring your correct dental insurance card to your appointment. A breakdown of benefits will usually explain your maximum amount, deductible, and percentages of coverage. However, even this will not tell us exactly what your insurance company will pay. Percentages are based on the insurance company’s allowable amount which most will not disclose and may be different per zip code. For example: Lets say we charge $95 for a cleaning, and the insurance company only allows $90. Then they will pay 100% of $90, and you would be out-of-pocket the remaining $5.

Cleanings Are Never “Free”

Hold on, let me explain! It’s true that most insurance companies cover two cleanings per years at 100% of their allowable amount. Because our rates for cleanings are competitive, and fall below the allowable amount for most insurance companies, most patients are not left with a balance. However, there are some exceptions to this rule. Remember, that disclaimer? If you’ve reached your maximum because you had some other work done earlier in the year, then insurance may not pay for your cleaning. If your cleaning is even one day earlier than six months, your insurance company may impose a frequency limitation. If our charge is more than your insurance companies allowable amount or their fee schedule is lower than normal, you may have some out-of-pocket expense. For these reasons, it is very misleading to imply that they are free.

Categories

There are three categories of coverage for most group insurance polices: Preventative, Basic, & Major. *Percentages of coverage for each category are based on the insurance company’s allowable amount which may be less than our fee. Orthodontic coverage is it’s own category and age limitations may apply.

Preventative. This category usually describes things that are routine in nature like cleanings, exams, and x-rays. These services are typically covered at 100% of the insurance companies allowable amount which may be different than our fee. Usually the deductible is waved for this category.

Basic. This category usually describes things like fillings, extractions, periodontal treatment, and sometimes root canal treatment. These services are typically covered at 80% of the insurance companies allowable amount which may be different than our fee. Usually the deductible is applied to basic services. Sometimes a 6 month waiting period will apply. Frequency limitations may also apply.

Major. This category usually describes things like crown, bridges, partials, and dentures. These services are typically covered at 50% of the insurance companies allowable amount which may be different than our fee. Usually the deductible is applied to major services. Sometimes a 12 month waiting period will apply. Frequency limitations may also apply.

*Reminder: The following information is based on averages of how most insurance policies work, and is intended as a guideline only. There are exceptions to every rule. For example: In rare cases, some policies may consider x-rays under the basic category, which means a deductible would apply and they would be covered at 80% of the allowable amount instead of 100%.

The Missing Tooth Clause

Oh, this is a fun one! (Just Kidding) Some policies have a “Missing Tooth Clause,” which states that if a tooth was missing prior to the effective date of the policy, the insurance company will not cover to replace it. The exception would be if you have a prosthetic in place to replace the missing tooth before the policy was in effect, and the prosthetic needs to be replaced.

Alternate Benefit

Insurance companies may apply an alternative benefit if/when the submitted service is not covered and would otherwise be denied. A good example of alternate benefit is silver fillings. Most insurance company will not cover tooth colored fillings on back teeth (molars & pre molars). Instead of denying the claim, they will apply the benefit for a downgraded option that is covered, which in this example is an alternate benefit of a silver filling. We strongly believe that science and technology no longer supports the advocacy for placement of silver fillings when there is a better option. Insurance companies may argue that the difference is cosmetic only, and silver fillings are adequate treatment. There are pros and cons to alternate benefits. The pro is that the insurance company will pay something toward a service that would otherwise be denied. The con is that the insurance company pays based on the allowable amount for the downgraded service which is typically much lower than the service that was done. Bottom line, it does cost a little more to place tooth colored fillings. The materials are more expensive, and the technique is a little more involved when compared to silver fillings. However, silver fillings contain mercury which is extremely harmful. So much so, that we are required to have a special machine installed to make sure that any silver fillings we remove don’t go into the septic. What do you think? Is the insurance company looking out for your best interest by applying an alternate benefit?

Pre-Estimates

Pre-Estimates are claim forms submitted to the insurance company prior to any service being started or completed. The intention is to obtain an estimate of what the insurance company will pay. These do not obligate you to treatment. They also are not a guarantee of payment from your insurance company and will be based on the eligibility, limitations, exclusions, maximums, and deductibles at the time services are rendered. We are happy to submit pre-estimates when requested. Patients should be advised that it can take up to six weeks for the insurance company to process these.

Primary & Secondary

Do you have two dental insurance policies? Don’t get too excited. You may need to reign in those expectations a little. Unfortunately the “Non-Coordination of Benefits Clause” may apply. This clause states that if your primary insurance pays more than your secondary would have paid if they were primary, then there is no additional benefit from your secondary insurance. Some people think that if a service is covered at 50% by primary, then secondary will pick up the other 50%, leaving the patient with no out-of-pocket. This simply isn’t true in most cases because most policies have the non-coordination of benefits clause.

We cannot file pre estimates to secondary insurance. Well, we can, but the information will not be accurate, because secondary claims are based on what primary insurance pays. The Explanation of Benefits from the primary insurance cannot be obtained until the services are complete and the insurance claim has been processed rendering it useless to file pre-estimates when secondary is involved.

How do you determine which is secondary and which is primary. Unfortunately, you do not get to choose. Your insurance through your current employer will always be your primary. Any insurance you have through a spouse or parent would be your secondary. When both parents carry children on each of their dental policies through their employers, the birthday rule applies. The birthday rule indicates that which ever parent’s birthday comes first in the calendar year will be primary. In the circumstance where parents are divorced, there may be a court order requiring one parent to carry dental insurance. Often this will need to be submitted to the insurance company to prove primary liability.

Insurance Cards

We do not magically know who your dental insurance provider is. I think some people assume that we have access to some giant database of information, and can just look it up. However, no such database exits, and for good reason. This is part of your private, protected health information. While, we have gotten pretty good at playing detective, the truth is we rely on you to provide this information Sometimes, we get lucky and already have your group information in our system, but it saves a lot of time if you present your dental insurance card. If you do not have a card, you should be able to go online and print one or email a copy. Most insurance companies provide important benefit information online, so it’s worthwhile to set this up if it’s available. Do not assume your dental information is on your medical card. In fact, it’s usually a separate company entirely. If you cannot find the word “dental” anywhere on your card, chances are you are looking at your medical insurance card. We’d much rather spend time at your appointment addressing your concerns, not trying to find out who your insurance is with. Please, take a little time to make sure you have this information before you arrive to your appointment. If you have no idea who your dental insurance is with, we advise you to contact someone in your HR department.

Medicaid / Medicare

We do NOT accept Medicaid. Use the link below to find a provider in your area who does.

Visit the SC Healthy Connections Website

Medicare does not cover dental expenses; however, some Medicare supplement polices purchased in addition to Medicare may. You’ll need to check your policy specifically to make sure you can see an out-of-network dental provider. We are NOT in network with any Medicare supplement policies. These policies tend to vary greatly, and a representative with your insurance can best help answer your benefit questions. A Cook Club membership may be a better option than purchasing an individual dental insurance policy.

Learn About Cook Club

HMO Vs. PPO

HMO (Health Maintenance Organization) typically requires that you see a provider in the network to receive benefits. PPO (Preferred Provider Organization) typically allows you to see the provider of your choosing whether they are in or out of network.