Dental insurance 101: understanding the basics

Jonathan Kaupanger
October 09, 2017 - 2:33 pm
A patient's eye view, as a dentist poses for the photographer on April 19, 2006 in Great Bookham, England. (Photo by Peter Macdiarmid/Getty Images)

By Jonathan Kaupanger

Private dental insurance is once again available to purchase through the VA Dental Insurance Program (VADIP). Veterans now have the option of either MetLife or Delta Dental of California.

Enrollment in either plan is voluntary and does not affect eligibility for VA outpatient dental services and treatment. Anyone who does enroll in either plan will be responsible to pay for the entire premium and any copayments.  Open enrollment starts Nov. 15 and coverage will begin on Dec. 1.

Enrollment for any insurance program is where things tend to get confusing, for me at least. So here’s some information to think about while picking which program is right for you and your family.  A good thing to remember is that dental insurance isn’t at all like medial insurance.  Dental insurance is designed with the purpose of only covering basic dental care, which is about $1,000 - $1,500 per year.  Sadly this is about the same amount that was covered 30 years ago too.

Yearly Maximum:  This is the most money a plan will pay per year.  The yearly maximum automatically renews each year, so if you have unused benefits, they do NOT roll over.  For many dental insurance companies the average yearly maximum is $1,000.

In/Out of Network Dentists:  Most dental insurance companies will only pay for dental services when you go to a contracted or participating “in-network” dentist.  Find out if you are required to go to a participating dentist or if you can pick your own.  If you have to use an in-network dentist, ask for a list of providers in your area so you can see if there’s a dentist you want to see.

Usual Customary and Reasonable (UCR): This is a fee guide.  It’s not based on what dentists actually charge, but instead on what the insurance company will pay for each procedure.  For example, let’s say you get a cleaning and it costs $85, but the insurance company only allows $65 because it’s the UCR fee they set.

If you are required to go to a participating provider, normally you won’t be charged the difference for the two prices. A contracted dentist normally will just write off the difference in charges.  It’s important to know what’s on the UCR, especially if your policy lets you go to a dentist of your choice.  You may be required to pay the difference.

Types of Coverage: All dental insurance carriers are different, so it’s very important to know what category each procedure falls under.  Some plans don’t cover major procedures, others have waiting periods for other procedures.

Most companies consider routine cleanings and examinations as preventative dental care.  Depending on the carrier, X-rays, sealants and fluoride can be considered preventative or basic types of services.

Basic or restorative treatment normally consists of fillings and simple extractions.  Root canals can be considered basic or major.  The majority of dental plans do list root canals under basic type coverage.

Major procedures are normally things like crowns, bridges, dentures, partials, surgical extraction and dental implants.

Dental Insurance Waiting Period is the time an insurance company makes you wait after you are covered but before they’ll pay for certain procedures.  Sometimes you end up waiting so long, you could have paid for the procedure by paying your premiums and waiting.  Pay close attention to anything that has a waiting period!

Missing Tooth Clause and Replacement Period: This is exactly what it sounds like and about 90 percent of carriers have this clause in place.  If you are missing a tooth before you sign up for insurance, then decide you want a bridge later, the insurance company won’t pay for the gaping hole that was there before you bought insurance.  Replacement clause just says the company won’t pay to replace things until a specific time has passed.

Cosmetic Dentistry:  99.9 percent of dental insurance companies won’t pay for cosmetic dentistry.  Do you need the procedure or is it just to make you look better?  If it’s the latter, it’s coming out of your pocket!

For more information on VA’s dental program you can go here or call 877.222.VETS (8387).


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