Dental Insurance Basics

Dental Insurance Overview

• Dental insurance is a plan that helps patients and families with the cost of dental care. A common type is an indemnity plan.
• Indemnity plans reimburse costs of dental treatment received from a dentist, but often have limitations and co-payment options.

Parties Involved

• Dental insurance involves three parties:
  • The client/subscriber (or insured person), who carries the plan or is a dependent of the subscriber (e.g., spouse or child).
  • The provider, typically a dentist, who provides the treatment.
  • The insurance carrier (company), which pays claims and collects premiums.

Group Insurance

• A group insurance plan may be purchased by a company for their employees.
• A plan administrator negotiates the plan's cost with the insurer. This negotiation affects the cost and coverage of the policy.

Shared Risk (Co-payment)

• To prevent abuse, dental insurance plans often have co-payments.
• The client is responsible for a portion of the cost.
• For example, if a client has 80% coverage for basic procedures, the insurance carrier pays 80% and the client pays 20%.
• Co-payment is a plan that requires the policyholder to pay a specific percentage of each claim.

Flexible Benefits

• Employees can select dental insurance coverage from options offered by their employer.

Insurance Company/Carrier

• Insurance plans from different companies and carriers vary significantly.
• Yearly maximum benefit limits per household are common. Examples of carriers include Great West Life, Sun Life, Blue Cross, Green Shield, Liberty Health, and Met Life, Aetna.
• Some plans pay for 100% of the cost, others have co-payments and some have deductibles.

Maximum Benefits

• Maximum benefits represent the highest amount payable during a specified time, such as a calendar year or the duration of the policy.

Deductible

• A deductible is the amount of money a client must pay before the insurance company starts to cover dental expenses.
• Annual deductibles are often set at a yearly or contract basis.
• Clients will have to pay the deductible amount before the insurance coverage kicks in. The amount is typically between $25 and $50.

Routine/Basic Coverage

• Routine coverage covers services for maintenance and preservation.
• Examples include fluoride treatments, scaling, fillings, root canals, radiographs, study casts, biopsies, extractions.

Major Restorative Services

• Major restorative services involve extensive procedures, such as crowns, bridges, dentures, implants, periodontal surgery, or oral surgery.
• Frequently, co-payments are required for these procedures.

Orthodontics

• Orthodontic services are for aligning jaws and teeth.
• Co-Payment is typical with these services.
• Orthodontics are often not a covered benefit under routine coverage.

Example of Group Insurance with Shared Risk

• Routine services have 80% coverage.
• Major Restorative procedures are typically 50% covered.
• Orthodontic services have 50% coverage.
• Deductibles are typically $25.

Assignment of Benefits vs Indemnity Contracts

• Assignment of Benefits: When a claim is submitted, the benefit may be paid directly to the dentist (not the subscriber) in accordance with the plan.
• Indemnity Contracts: A subscriber pays their dentist, then submits the claim to the insurer for reimbursement. The insurer often only pays benefits as services are rendered.

Birthday Rule

• When a child from different parents is covered under two or more policies, the birthday of the child determines the primary carrier.
• If birthdays are the same, the oldest policy is the primary policy.

Calendar Year

• A calendar year is one year, from January 1st to December 31st.

Carrier

• A carrier is the insurance company that provides the insurance.

Group Policy

• A group policy is an insurance policy for a specific organization or business group. Only members of that group may belong to that policy.
• Companies often have multiple policies.

Claim

• A claim is a listing of dental services, fees, and dates submitted to the insurer.

Coordination of Benefits (COB) or Co-insurance

• COB/Co-insurance is used when multiple family members have dental insurance.
• Families coordinate the insurance benefits to cover the total cost of the dental services.
• The primary carrier pays first and sends remaining balances to any secondary carriers. Payments together can't exceed 100%.

Who do you send to first?

• This section presents examples of which insurance policy should cover claims first.

Preauthorization/Predetermination

• Preauthorization is a request to the insurance to confirm if, and how much, covered treatment will be paid by the policy.
• This request is often sent with a claim form, marked as "Pretreatment Estimate."
• The claim form is resubmitted after all services are complete.

Provider

• A provider is the professional who renders the service, such as a dentist or hygienist.

Dependent

• A dependent is a person covered under a policy who's not the primary policy holder. A dependent may be a spouse, a child, or an elderly parent.

Exclusion

• An exclusion is a dental service or procedure that is not covered under the benefit plan.

Insured

• The insured is the person who owns a dental insurance policy. (The policy holder).

Limitations

• Limitations restrict the coverage, Such as service restriction examples being a 6 or 9 month recare cycle.

Dental Claim Form

• A claim form is a preprinted or computer form that documents insurance information for reimbursement. These forms contain information regarding the insurer, dentist, service provided, fees, and other relevant data.

Tooth Surfaces

• Tooth surfaces are identified using letters (O/I, M, D, V/B, L) to indicate occlusal/incisal (biting surfaces), mesial (front surface), distal (back surface), vestibular/buccal (outer surface), and lingual (inner surface).

EDI

• EDI is a format for electronic data exchange between sending and receiving companies to streamline transactions.

Insurance Fraud

• Insurance fraud is illegal. Misrepresenting treatment, inaccurately reporting fees, or billing for non-provided services violates the law.
• Fraud can result in fines and imprisonment. Fraud by an office/DDS/staff and fraud by the client are described.

Test your knowledge of dental insurance terminology. Questions cover topics such as co-payments, coverage negotiations, and the roles of different entities involved in dental insurance plans. Also, a question about dental chart notations.