Westport Plaza Dental
A Great Dentist

The Never-Ending Maze of Insurance

September 28, 2020
Posted By: Jodi Turner
Woman standing in front of a maze on the wall

The Never-Ending Maze of Insurance


It’s getting close to the time for open enrollment.  I thought now would be a good time to give everyone the reminder that most insurance plans reset January 1 so if you have benefits left now is the time to use them or you will lose them.  That being said, lets get into some of the common questions we get as a team here at Westport Plaza Dental Associates in regards to insurance plans and some of the crazy rules that insurance has that can lead us into the never-ending maze of questions. 

To start, WPDA is in network with Delta Dental Premier and Cigna PPO.  What does that mean?  Since we participate with those two plans, we have agreed to use their fee schedule (prices insurance sets for treatment).  Below is a hypothetical example of how this works. 

Tooth Colored filling       $250.00

Insurance Fee Schedule $150.00

Patient coverage is 80% of the Insurance Fee Schedule or $120.00

Patient out of pocket is $30.00

This break down is very generic and we wish things were that simple.  Unfortunately, insurance plans often place rules or limitations on coverage.  The next section will give you an outline of some of the many rules or limitations that are present on a lot of plans.  This is why we encourage our patients to please read the handbook that is given to you when you sign up for your benefits.  The provider is not obligated to provide your coverage information, but will make inquiries as a courtesy to the patient because they know what questions to ask.  Below is a list of common rules based on the type of coverage.  All patients should know if their plan has Preventative, Basic, and Major coverage. 

Preventative coverage is how it sounds.  Cleanings, exams and x-rays typically fall under preventative.  Other common preventative items are fluoride and sealants.  Here are some common questions to ask your benefits provider when signing up for a plan. 

  1. Do my cleanings need to be 6 months apart or just 2 times a year?
  2. Does my plan allow for additional cleanings if I have a pre-existing condition such as diabetes or cancer?
  3. Do my cleaning and check ups take away from my yearly maximum?
  4. Do I have adult fluoride coverage? 
  5. Do all of my x-rays fall under preventative or are some covered under basic?
  6. How often are sealants covered?
  7. How often is fluoride covered on children?

Basic coverage has a little bit more to it.  Periodontics, endodontics, oral surgery and fillings fall under basic.  Coverage varies based on plans that your employer or yourself have picked.  Some plans cover basic 90%, where another plan may only cover 30%.  This is why its so important to know what you are signing up for.  Another factor on this coverage is your deductible and yearly max.  Deductibles for dental insurance are different than medical.  Deductibles for dental plans range from $25 and up.   Dental also differs from medical in regards to the yearly max.  Dental insurance set a cap on coverage.  Your plan may state that you have $1000 to use for the year.  Once you have used that amount your dental insurance is considered maxed out.  At this point insurance will no longer cover services provided by your dentist or hygienist.  It is very rare for a dental plan to offer an unlimited max.  It should also be noted that an increase in your yearly max and percentage of coverage will equal a higher premium for you.  Let’s see what some of the common questions for basic coverage are.

  1. How many periodontal maintenance cleanings (cleanings for patients who have been diagnosed with gum disease) are allowed a year?  Tip! Sometimes insurance plans will allow 3 instead of 2 a year if the patient has a pre-existing condition. 
  2. Does my plan cover tooth colored fillings on my posterior (molars/premolars)?  Attention! Plans will downgrade the coverage to an amalgam (silver/alloy) filling leaving the patient with a higher out of pocket cost.  WPDA does not provide amalgam fillings. 
  3. What are the replacement rules for a filling? Example, you had a filling done January 2019.  The filling was done on the top of your tooth (occlusal).  12 months later you come in for your cleaning and check up and now have a cavity on that tooth in between the teeth.  Will your insurance cover another filing on that same tooth?  Tip!  Most plans have a clause that a tooth CAN’T have treatment again for two years. 
  4. Does my plan cover bone grafting after an extraction? 
  5. Most importantly is there a waiting period before I have any basic services?

Major coverage includes crowns, bridges, partials, dentures and implants.  Just like basic a deductible and yearly max will apply to this coverage.  Let’s jump into the common questions. 

  1. Does my plan covered tooth colored crowns on the posterior (molar/premolar) teeth?  Just like fillings some plans have a downgrade clause that will cover an alloy crown over a tooth colored crown.
  2. What is the replacement clause for a crown, bridges and prosthetics (partials/dentures)?  Most plans will only cover a crown 1 time every 5 years.
  3. Are implants covered under my plan? Attention! Implants are not always covered by insurance.  Please make sure to see if all parts of the implant are covered.  Placement of the implant itself and then the restorative end of the implant. 
  4. What is the replacement clause for an implant? Attention!  Most insurance plans only cover having an implant placed one time.  If an implant fails the insurance may not cover a replacement. 
  5. Will my insurance plan cover a bridge or will it downgrade to a partial if I have missing teeth on the other side of my mouth? 
  6. Do I have a missing tooth clause in my plan?
  7. Tip!  Did you know that sending in a pre-authorization for services still does not guarantee payment from insurance?  That’s right!  Everything given to you is strictly an estimate whether from the doctor or insurance.  Nothing insurance wise is guaranteed except your monthly premium!

Making sure you pick the right plan can be overwhelming.  As you can see there are a pretty long list of things to think about when picking a plan.  We haven’t even asked all the questions there are to ask!  Hopefully having some of these questions before hand can help you make a better decision.  Sometimes employers are not even aware of the hidden clauses with insurance.  The best place to get answers is from your insurance handbook or the insurance companies themselves.  You have a right to ask these questions.  If you don’t have a handbook that details the fees your insurance have listed for services then I would definitely request that from insurance.  The more information you have from insurance the better prepared you will be.  I hope this helped you get ready for the upcoming year. 

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