Am I covered?
This is one of the most common questions that our patients ask us, whether it is in response to a recommended treatment plan or just a general inquiry.
It is an important question because it is obviously one of the greatest factors that a patient takes into account when considering dental treatment. And although, treatment may be necessary for your dental health, no one wants any surprises when it comes to finances.
“It is becoming increasingly difficult for dental practices to gather information from your insurer on your behalf.”
Even if you already have an employee booklet that was given to you by your employer, it can sometimes be difficult to interpret or may not explain all the limitations your plan may apply to your covered benefits. Under Ontario’s Privacy Act, it is becoming increasingly difficult for dental practices to gather information from your insurer on your behalf. Oftentimes, they want the subscriber of the plan (the employee) to be present in the office to grant permission and that is not always practical.
When a patients needs to be seen by a dentist for an unexpected emergency or last minute appointment, they do not always have the luxury preparing for their visit. If we have to initiate immediate treatment in order to save the tooth, waiting for approval of a cost estimate is also always a choice. An inquiry to the insurer over the telephone about treatment eligibility can be further complicated if they do not wish to disclose the information about the plan’s benefits without the policy holder’s written permission (regardless of the emergency circumstances) or they want to review the treatment case and dental images first.
This is just one of the many scenarios that take place when dealing with dental insurance. It can be an exercise in frustration especially when you are faced with having to make an immediate or timely decision about your dental health needs. When treatment cannot be delayed and is a same-day necessity, the uncertainty of insurance coverage can trigger an additional worry for patients.
Understanding your dental policy and the terminology used can be confusing. If you ever want to call your insurer to get a general breakdown of your policy there are a number of important terms and questions you may want to know and understand before making an inquiry:
Basic Services – Most insurance companies classify routine maintenance and restorative treatment under basic services. These include, but may not be limited to, exams, cleanings, fluoride, x-rays, sealants, fillings and extractions. Your plan will likely limit the frequency under which they will pay for such procedures and you should be aware of these date/frequency limitations.
When making an inquiry to your insurer, you would ask: “What procedures are considered Basic under my policy? How often can will these Basic services be performed?”
Major Services – Most insurance companies classify Major as those services that go beyond the scope of routine procedures because they involve more complex or extensive treatment in order to restore or repair a condition where breakdown, loss or damaged has occurred.
When making an inquiry to your insurer, you would ask: “Am I covered for major services? What are those major treatments and the associated limitations that I should be aware of?”
Fee Guide (aka. Fee Schedule) – is an annual suggested fee structure that is put together by a provincial or state dental association and serve as a guide when dentists are billing patients. Most insurance companies will base their fees according to this annual fee schedule. In order to make a dental plan more affordable for an employer to offer to employees, they may choose a plan that pays at a previous year’s suggested fees. For example, if you have an appointment in 2017 and your dentist bills you at 2017 prices, but you plan pays out at 2015 prices, you will pay the difference in fees between these two dates. From year to year, some dental fees increase, some decrease, while others may remain the same price. Dentists are not required to follow any fee guide, but most do. If the dentist practices a specialty such as oral surgery or endodontics you should inquire about their fees.
When making an inquiry to your insurer, you would ask: “What fee guide does my plan follow?” “Does it cover both General and Specialist practitioners?”
Deductible – Similar to a car deductible, it is the annual dollar amount you must pay before your insurance policy takes effect. It usually is an annual deductible and is applied to your first visit of the year. You may have a deductible for each member on your policy or just one for the whole family.
Case Scenario 1: If your first visit of the year is a covered expense under the terms of your policy and you are charged $100.00 for the treatment, under a policy family deductible of $25 your insurer will pay $75.00 ($100 minus the $25 deductible). Subsequent dental treatment for your family members within the year will not be subjected to this deductible as it has already been applied.
Case Scenario 2: If your first visit of the year is a covered expense under the terms of your policy and you are charged $75.00 for the treatment, under a policy family deductible of $100 your insurer will pay not pay anything as the $100 deductible has not been met yet. In fact, there is $25 still outstanding and will be applied to the next visit in that particular year. Subsequent dental treatment for your family members within the year will not be subjected to this remaining deductible as only $75.00 has been applied.
Sometimes, the deductible is only applied to certain treatment procedures such as major services. Understand that any premium or co-payments usually do not count towards this deductible.
When making an inquiry to your insurer, you would ask: “Does my policy have a deductible and is it single or family? How much is the deductible? Is it applied to all covered procedures or only certain treatment?”
Annual Maximum – Most dental plans have a certain dollar amount that they will pay towards your dental treatment per year. It involves a specific benefit period (January to December for example) and once this maximum dollar is reached then you are responsible for paying any remaining costs. It is important to understand that, if at the end of this benefit period, you still have a portion of this dollar amount still available and do not use it, it is usually lost and does not carry over into the next benefit period. Annual maximums vary depending on the policy and they are another way that employers and insurers limit their costs. There may be a different dollar amount applied to basic treatment as opposed to major services. It may also be applied to each individual under the policy or be a dollar amount for the entire family.
Case Scenario 1: If you have an individual annual maximum of $1000 and you have seven cavities totaling $700 and have not used any other monies from your plan during that specific benefit period, then you still have $300 remaining.
Other consideration that can affect this dollar amount of deductible, co-payments and type of dental services – basic or major.
Case Scenario 2: If you have an individual annual maximum of $1000 and you have seven cavities totaling $700 and have not used any other monies from your plan during that specific benefit period, but your plan only pays 80% for this type of basic treatment and has a $25 deductible, then they will pay $535 toward the dental cost leaving you with $465 remaining.
Unfortunately, the annual maximums that many insurance companies offer do not match the realty of today’s dental healthcare costs.
When making an inquiry to your insurer, you would ask: “Does my policy have an annual maximum? Is it a single or family maximum? What period does it cover? How is it applied – basic, major towards any treatment? What happens to remaining dollars at the end of the benefit period? Does my policy have a lifetime maximum? How can I best keep track of this annual maximum?
*TIP – Sometimes, a patient needs a lot of dental treatment during their benefit period. They may choose to have only the treatment that is covered by their annual maximum, and then delay the remaining treatment until their benefit period renews. Sometimes, it may be a viable option for you, while other times, delaying dental treatment can lead to higher costs in terms of fees, pain, complications and disease progression. Always consult your dentist if you are considering delaying recommended treatment. Oral health can be unpredictable, especially if you do not visit your dentist on a regular basis.
Co-Payments (aka. co-insurance) – is the percentage of the procedure bill that your insurance does not pay. It is your portion of the dental cost. If your dental office bills your insurance directly, then you will pay this fee after each dental visit. If you pay your dentist first and are reimbursed by your insurer then they will pay the covered costs minus this co-payment. Co-payment are usually expressed as percentages.
Case Scenario: your dental policy may cover basic procedures at 80% and major services at 50%. You will be responsible for paying the remaining 20% or 50% respectively. For basic treatment, your insurer will pay $60 of a $75.00 dental bill. If you were charged $500 for a major service your insurer will pay $250.00. Other factors will also be accounted for such as annual maximums and deductibles etc…
Again, it is a way for employers or insurance companies to limit their costs of offering dental coverage. Not everyone is fortunate enough to have a dental policy that covers 100% of all treatment. Like a deductible, a co-payment represents your portion of your dental expenses. Some patients ask their dentists to waive or write-off their co-payments, but each dentist in Ontario has a legal and ethical obligation via-a-vis the insurance company to collect all co-payments from a patient.
When making an inquiry to your insurer, you would ask: “What co-payments am I responsible under this policy? Are there different co-payments for different types of procedures?”
Coverage period – This term basically means the period of time for which you or a member of your dental plan is covered for insured benefits. It can be used to describe a benefit year or the period of time that your policy is in effect. Some plans kick in only after a specified “waiting period”, so it is essential that you call your insurer to ensure that you are eligible to use the plan before you make a dental appointment. Additionally, you may only be covered for basic services for a period of time before any major coverage applies.
When making an inquiry to your insurer, you would ask: “When is the exact date that I can begin using this plan?” “Up to what age are my dependents covered and what conditions apply?” “What happens if I am laid-off or go on leave from my job?” “Is there a wait period for any procedures such as major treatment? “Is there anything else that can affect my eligibility under this plan.”
Single/Family – Single refers to the individual policy holder/employee and Family includes their spouse and at least one child. Single coverage usually costs less in premiums than a family plan. Clarify with your insurer who is covered under your plan and ensure that their personal information (spelling of name, date of birth etc…) is correct. If you are living in a co-habitation arrangement with a common-law spouse or separate with your spouse, ensure that you understand how it can affect their eligibility under the plan. Lastly, you may want to know if your yearly deductible applies to the family as a whole or each individual member of the plan.
When making an inquiry to your insurer, you would ask: “Does my policy cover my family?” “Do we have one maximum dollar amount for the whole family or do we have individual annual maximums?” “Is my plan’s annual deductible single or family?”
Frequencies – Your insurer often limits the number of times that they will pay for a particular dental procedure. The time lapse between two identical procedures and the limitation your insurer will place on having the same procedure performed again can be very problematic for patients if they are not aware of these plan limits. For example, you may be covered to have a check-up examination every 6 months. There are other plan frequencies applied to different treatment such as crown replacement (ie. every 5 years), orthodontics (ie. once in a lifetime), fillings (ie. once every 3 year for same tooth, same surfaces) or new patient exam (i.e. once every 36 months).
When making an inquiry to your insurer, it becomes a little trickier when asking about frequencies. If you think that a tooth has had dental tx performed on it in the past, your dental provider can make this inquiry to your insurer on your behalf.
Examinations – There are different types of exams that a dental provider may perform. The exam that is arranged for you depends on the situation and the amount of time involved for the dental provider.
Complete Exam (Procedure code 01101 baby teeth, 01102 mixed baby and adult teeth, 01103 adult teeth) – Exams that warrant a complete verbal, visual and radiographic (x-ray) evaluation of a new patient or of an existing patient that requires a more comprehensive assessment of their oral health status. It generally centers around in-depth information gathering to the extent that allows the dental team to acquaint themselves with a patient’s past medical/dental history, chart pre-existing dental work, diagnose current conditions and develop a plan for future care. Most insurers pay for this every 2-3 years.
Recall/Check-up (Procedure code 01102) – A regular, periodic maintenance examination of a pre-existing patient to ensure no dental problems/issues have arisen since your last check-up exam. It usually coincides with a regularly scheduled cleaning. Every 6-12 months
Emergency Exam (Procedure code 01105)- An exam that is required in an unexpected, urgent situation such a fractured tooth, extreme pain or swelling of an area of the mouth. Insurers may limit how many of these exams can be done outside of your regular check-up exam.
Specific Exam (Procedure code 01104)- An examination that is required apart from your regular check-up exam for the assessment/diagnosing of a specific area or tooth of concern and is not urgent in nature. Again, your insurer usually place limitations on the frequency of this type of exam.
When making an inquiry to your insurer, you would ask: “How often can I have a check-up exam?” “What are my plan’s frequencies concerning emergency and specific exams” “How often can I have a complete new patient exam?”
Specialist – If you have been referred to a Specialist, typically their fees are higher than the suggested provincial fee guide for General dentists. Additionally, you will usually pay up front for your treatment at a Specialist office and be reimbursed by your dental insurer according to the terms of your policy. Although your insurer may not cover all of the fees, it may at least defray some of the cost. Ensure that you know the payment policy of the Specialist you will be seeing and how you are to submit a claim for treatment to your insurer.
When making an inquiry to your insurer, you would ask: “Does my policy covers Specialist fees and at what percentage and up to what maximum dollar amount?”
Composite on molars – This is term that is used to describe a white filling on a molar. Some plans will only pay for an amalgam fillings on back teeth where aesthetics are less of a concern since most people cannot see your back teeth. Many dental offices no longer provide amalgam material as a choice for fillings when a tooth is decays or fractures. There is a cost difference – with the composite white filling being slightly higher in price – so insurers will scale their payment of white fillings to the amalgam price.
When making an inquiry to your insurer, you would ask: “Does my plan cover composite on molars?”
Dual Coverage – This is when a patient has dental coverage through 2 separate dental plans – usually their own plan and then an additional plan through another employer, school, spouse or partner. Other dependents and children oftentimes have coverage through both parents. When there is eligible coverage under 2 dental plans one becomes the Primary plan that pays first and the other plan is the Secondary policy that pays all or some of the cost that the Primary does not. When submitting your claim to your Secondary insurer, you will need to enclose proof of Primary insurance payment before they will cover the remaining cost. You may not “double dip” meaning – both insurers require that you fully disclose the presence of dual coverage as you cannot claim your dental fees in such a manner that results in both the Primary and Secondary insurers reimbursing you or the dentist for more than 100% of the claim. Having 2 plans to help defray the cost of dental treatment helps to lower your out-of-pocket expenses, not profit from it. When your Primary claim is submitted, it will include details that will indicate to your Primary insurer that you have Secondary coverage and vice versa. If, for whatever reason, you no longer have the benefit of a Primary plan, you may need to provide proof to the Secondary insurer before they step up to their new position as Primary Benefit provider.
When making an inquiry to your Secondary insurer, you would ask: “What kind of proof do you require to pay a Secondary claim?” There are two types of Statements of proof that are available – both referred to as EOB: Explanation of Benefits. One is the statement that the Primary carrier sends along with the dental cheque (it may be in postal, email or online form) while another form of proof that is sometimes accepted is the insurer’s response to the electronic submission that your dental office sends over a specific carrier network online and has the phrase EOB on the response.
Secondary payments – The is the benefit/money that is paid by a Secondary insurer as in the case of dual coverage or a Health Spending Account. See above. They are not the initial insurer that pays for a dental claim.
Health Spending Account – A Health Spending Account is a type of benefit that provides payment for healthcare-related expenses that are over and above any insurance benefits that an employee may have. Typically, a patient would pay the dentist bill first then provide receipt of payment to their HSA for reimbursement.
When making an inquiry : You would make any inquires about a HSA to your employer or Human Resources department.
Orthodontic coverage – This refers to any type of treatment involving re-positioning of teeth like dental braces. It is typically categorized under major treatment and often has it’s own lifetime maximum and co-payment limitations. Generally, your orthodontic provider will submit a treatment plan to your insurer for consideration before any benefits will begin to be paid out and usually these costs are paid out over the course of the treatment.
When making an inquiry to your insurer, you would ask: “Does my policy include orthodontic coverage?” “What is the maximum dollar mount I can claim under orthodontics and is it a lifetime maximum?” “Is there an age restriction?” “Does treatment have to be provided by an orthodontist?”
Assignment of benefits – As a courtesy to patients, some dental offices will submit and bill your insurance company directly then wait for payment of the covered portion of treatment. Dentists are not required to do this. The full cost of the procedure is ultimately your responsibility. Understand, that many offices may not offer assignment of benefits for a number of reasons. It is getting increasingly difficult to do business with or make inquires on behalf of patients to insurance companies who implement very strict information policies based on their interpretation of Ontario’s Privacy Act. Lastly, dentists treat you based on your needs – not your dental plan. A dentist is still obligated to recommend treatment based on sound, evidence-based diagnosis even when your benefits do not completely match your health needs. Providing dental care while being a third party and fee collector to an agreement between a you and your insurer is a relationship that many healthcare providers do not wish to engage in.
When making an inquiry to your insurer, you would ask: “Will you make payment directly to my dental provider?” “Do you accept electronic claim submissions?” Your dental office will then have additional information about this electronic claim process.
Estimates – A written treatment plan (and images/x-rays, if requested) that is submitted to your insurer to determine whether any or all of the dental procedures in the treatment plan will be covered by your plan. Most insurers no longer provide verbal authorization over the telephone and recommend that you send them an estimate for any treatment over $300-$500. In this way, you will know in advance what your plan will cover and what your out-of-pocket expenses will be. It is important to remember that a pretreatment estimate does not guarantee payment from your insurer. Your insurer will calculate benefits according to your current eligibility, any deductibles that may be applied and how much is remaining of your yearly allowed maximum.
When making an inquiry to your insurer, you would ask: “Can you tell me over the phone if I will be covered for “such and such” treatment. If not, approximately, how long will the estimate process take?” When making an inquiry to your dentist, you would ask: “Will you submit an estimate to my insurer for the proposed dental treatment and await their reply before we proceed?” Will it be safe to postpone advised treatment until my insurer replies?”
Age Limitations – This is another restriction in coverage and applies to limiting or denying benefits based on age. An example is fluoride or orthodontic braces that may be limited to children under a certain age or the termination of coverage once a dependent reaches adulthood. Many plans allow dependents to still remain eligible for benefits as long as they are still in school full time and can provide proof of this. Ensure that you provide your insurer with any pertinent information they require for your post secondary school aged child to remain eligible.
When making an inquiry to your insurer, you would ask: “What are the age restrictions that limit the eligibility of any members on this plan? What information do you require in order for my post secondary children to remain eligible?”
*TIP – Know the date when your child will no longer be covered under your policy due to any age/school restriction and ensure that they receive a comprehensive dental examination and complete any recommended/outstanding treatment before this date. Waiting until last minute will put unnecessary time constraints on both you, your dependent and your dentist.
EOB – A statement issued by your insurer showing what the dentist billed for each procedure and how much the insurer paid. Oftentimes, the statement will contain additional information with respect to why a particular procedure was not covered, the remaining balance of your yearly allowable maximum and perhaps some information pertaining to frequencies.
When making an inquiry to your insurer, you would ask: “How will I receive an accounting of what my dentist billed and what you, the insurer pays – Email? Online? Mail?
Alternative Provision: When it comes to dental treatment, your dentist will usually make recommendations based on your individual circumstances. You may be fortunate enough to have several different options available to you. When it comes to options, however, each option generally comes with their own set of advantages/disadvantages in terms of cost, material, long-term prognosis (outcome), stability, patient comfort and compliance, success, limitations, etc. When it comes to your insurer providing payment for any particular treatment, you are limited to the terms of your policy.
Alternative Provision 1: Your insurer may agree to pay for your treatment, but only if your choose a less costly option or another treatment option of their choosing. The least expensive alternative is not always the best treatment option for you. For example: Your dentist may suggest a crown for a tooth that has been heavily restored and your insurer may only pay for the tooth to be repaired using pins and filling material. What happens when that tooth breaks sooner than later because the filling did not provide the necessary coverage/support/strength? What happens if the break extends down into the root and the tooth has to be removed?
Alternative Provision 2: Your insurer may agree to pay for your treatment, but will only pay out at the price of a less costly option or another treatment option. For example: Your dentist may suggest an implant in the area of a missing tooth. Your plan may provide benefits for a less expensive option, but agrees to pay for your implant, but only up to the price they would have paid for the less costly option.
It’s great to have dental coverage until you find out that your plan does not cover your individual needs – needs that become more complicated with due to age, neglect accidents, disease or wear. Remember, your dentist treats you not your dental plan.
Pre-existing Conditions – There may be a clause in your policy that restricts benefits if your particular condition already existed before you had your current dental plan. One such common condition is the “Missing Tooth.” If your dentist recommends that that you replace a missing tooth/teeth with a bridge, implant or denture, but this tooth was removed before you were insured under your dental plan, your insurer may not pay any money towards restoring your condition back to ideal dental function. Likewise, for treatment of gum disease if they can prove that the condition of your gums and supporting structures of the periodontium were already compromised before your plan came into effect.
This is a lot of information to take in.
In dentistry, we work with many, many different types of dental plans – all with various limitations and rules. Although a dental office may become familiar with a certain number of dental plans in their particular area or community, it is not practical to expect dental staff to be fully knowledgeable of all the individual plans available.
Your dental coverage is usually part of an overall benefits package offered by your employer and is designed to help employees offset their healthcare expenses. It is generally not based on your dental care needs – needs that are necessary to keep your smile happy and healthy!
Help Us to Help You!
Prevention is the number #1 way to keep dental costs down!
Prevent dental disease by practicing good oral hygiene and nutrition.
– Brush and floss daily
– Limit sugary drinks and snacks
– Don’t smoke or use tobacco/marijuana products
– See your dentist at least once a year for a thorough examination and cleaning.
– Except for water, space your food intake to 4-5 hours apart to allow saliva to repair damage from acid attacks. – – If you must snack, choose raw, crunch vegetable or fruit.
Prevent insurance complications for your dental office by informing them of any policy or personal life changes that could alter your coverage such as: changes to employment status changes (as in the case of a temporary layoff), a child in post secondary school or a change in marital status.
Prevent small issues from becoming bigger problems by maintaining regular recare visits and attending to dental issues when they are small and under control. This will go a long way in reducing the likelihood of unexpected emergencies and their associated costs in terms of pain, dental fees and future restorative care.
Prevent dental cost surprises by understanding the ins and outs of your dental plan including what’s covered, limitations and what you are expected to pay before having treatment done.
Prevent future worries by taking the time now to consider future dental costs when planning for your overall healthcare needs in retirement.
Prevent disappointment by taking the time now to discuss treatment options and expectations with your dentist. This includes asking about any risks, future maintenance, long-term prognoses, as well as the consequences of delaying or opting out of treatment.
Prevent any miscommunications by practicing good dialogue techniques with your provider, including the insurance company. Practice active listening, repeat back what you understand and ask for clarification when necessary, be open about your concerns including financial considerations, voice any objections immediately, know what your portion of the bill will be etc…
Understanding dental insurance is crucial to making smart decisions about your dental plan’s features. Now that you have a solid grounding in the basics of dental insurance, you’ll be better prepared to understsnd you own plan’s features and help you and your family get the dental care you need!
Who’s taking care of Your Smile?