Dental insurance can be confusing at times, and sometimes patients don’t understand how their procedures will be covered. While dental office staff can help answer questions, particularly about more common plans, the most accurate advice will come from the insurance company itself. Every plan is different, and there are some plans that are very different from the most common PPOs and DMOs, so it’s always best to talk to your insurance broker, human resources department, or the carrier itself. With that being said, here are some frequently asked questions about dental insurance.
Do I Need a Referral to See a Dental Specialist?
If you have a dental PPO, you usually do not need a referral, though there are some exceptions. If you have a DMO, which is the dental version of an HMO, you do. You can check your dental insurance card to see if it says what type of plan you have. Another clue is that if you pay a certain percentage of a procedure, you likely have a PPO; if you pay a set copay amount, it’s more likely a DMO. Again, these are general guidelines and do not apply to all plans. If you want to see a specialist, call your dental insurance to find out for sure whether a referral is needed.
How Much Will My Insurance Pay Out Each Year?
Many (though not all) plans come with a calendar year maximum. This is the maximum amount of money that the carrier will pay the dentist. It doesn’t include your deductible or your portion of each procedure. In some cases, it does not include preventative care (cleanings and x-rays), but in other cases, it does. If you bring your insurance paperwork into your dental office, the staff can often read through to find out what your maximum is. Calling the dental insurance will tell you how much of your maximum you’ve used.
Do I Need to See Someone In Network?
To maximize the benefits of your PPO dental insurance plan, you should see an in-network dentist, but it’s not required. The plan will simply pay less if you choose to see an out-of-network dentist. If you have a DMO plan, however, you must see someone in network if you want them to pay at all, with very few exceptions.
Why Is My Out-of-Pocket Expense Higher Than I Expected?
Your dental office staff will do their best to verify your coverage. Sometimes, however, it’s impossible to get the most accurate information. For example, if you are closer to reaching your maximum than we thought because some of your dental work for the year hadn’t been paid out yet, this will often increase your out-of-pocket expenses. If the dental office does not participate with the insurance company, they might not know what dollar amount will be covered. Also, some procedures might have a waiting period. You can always call your dental insurance with the specific dental procedure codes to find out what they will pay.
We will always try to work with you, your dental insurance, and your budget when it comes to scheduling and completing your dental work. Please talk to a member of our office staff about your coverage and also about how you can arrange to pay your coinsurance, copay, or any other amount that is not covered by the dental insurance.
Creative Commons image by Pictures of Money.