Does the thought of dental insurance make your head spin? If so, you are not alone. We find that the average dental consumer knows only the basic information about their dental insurance plan. Fortunately, we are here to help the best we can! Yesenia and Emmaour administrative staff have extensive knowledge of most dental insurance plans. They work diligently to help ensure that our patients understand, utilize and maximize their dental benefits. Don’t worry, they’ve got you covered! In the meantime, you might find the following dental insurance terminology to be helpful. If you have any further questions, please do not hesitate to call us at 978-717-5819!
• Annual maximum:
The maximum dollar amount that the insurance company will pay for your dental care in a benefit year.
• Contracted dentist:
A dentist who has contracted with your insurance company. The dentist agrees to accept the insurance’s allowable contractedrates.
• Contracted fee:
The contracted allowable rate that the contracted dentist has agreed to accept as determined by the insurance company.
A dollar amount that the patient must pay for covered services. Your insurance determines what type services the deductible will be applied.
• Out-of-pocket expense:
The dollar amount the patient is responsible for paying, such as co-payments, deductibles, non-covered services and any amount over the annual maximum.
• Preferred Provider Organization (PPO) plan:
A reduced fee-for-service plan that allows enrollees to visit a Preferred Provider (dentist)this will minimize your out-of-pocket expense. Some patients have both a PPO and Non PPO insurance plan (In and Out of Network Plan) if both plan benefits are the same then it doesn’t matter who you see. Many PPO plans require you see a PPO dentist only.
• Waiting period:
A period of time that the insurance company has determined a patient must wait before their insurance becomes active and are eligible for benefits under a specific insurance type category.
• Missing tooth Clause:
When the insurance company will not provide any benefit coverage for that missing tooth. Generally, when themissing tooth occurred prior to having coverage with the dental insurance plan.
• Alternate Benefit:
When, there are two or more clinically acceptable dental procedure codes available, some insurance companies will apply what is called an alternate benefit. You are responsible for the additional charges beyond the allowance for the alternate service, even if using an in-network provider. For example: The alternative to a composite filling (white filling) is an amalgam filling (silver). The insurance will pay a benefit for the amalgam and the patient would be financially responsible for the difference between the two. This applies to what is considered as posterior (back) teeth.
Some insurance companies apply an alternate benefit to crowns and other procedures.
• Fee Schedule:
A list of procedurecodes where your insurance company and your employer group determine a dollar amount attached to a specific procedure code. That dollar amount is what they are going to pay towards the treatment making the patient responsible for the difference of that dollar amount and the dental office fee for that specific procedure code.
• Insurance Breakdown:
When we say insurance breakdown we are talking about what your insurance company has provided us regarding your coverage, via website, phone or fax. This breakdown provides us with the percentages of benefit coverage.We do not always see restrictions or non-covered services. We will only provide you with estimates.
Ultimately, it is the responsibility of the patient to know what type of insurance benefit coverage is available to you. Your insurance contract is between you, your insurance company and/or employer group. We will try our best to help with any questions. Although, we suggest you always call your insurance company for answers to any questions regarding coverage.