Posted by: Jason Hui, DDS, on October 12, 2013
The end of 2013 is just around the corner, and we know that everyone will be busy preparing for the multitude of festivities during the upcoming holiday season. Before getting swamped with cooking Thanksgiving dinner, shopping for Christmas presents, and making New Year’s resolutions, Paragon Dentistry would like to remind you that your dental insurance benefits will be expiring soon. We have received many questions about the way insurance benefits work and wanted to take the time to elucidate this matter.
Every individual with dental insurance receives an allotted annual maximum amount that the insurance company will pay. To facilitate this discussion, we will use arbitrary sample numbers; these numbers will differ depending on your insurance benefits and recommended treatment. If your individual annual maximum is, say, $1500, this means your insurance company will pay up to $1500 before they stop paying. Now, how much your insurance pays per procedure varies dramatically. Preventive procedures such as exams, x-rays, and cleanings are generally covered at 100%, which means insurance will pay the entire fee, and your patient portion will be $0. Speaking in general terms, procedures such as dental fillings, tooth extractions, and root canal treatment tend to be covered in the 50-80% range; major procedures such as implants, crowns, bridges, or dentures tend to be covered at 50%. Specific percent coverage depends on each individual’s insurance plan benefits. The bottom line is insurances will pay a specific percentage of each procedure up to the annual maximum (in this example, $1500). Once the annual maximum amount is reached, the patient will be responsible for 100% of the fees.
What this means is if you have any outstanding dental treatment that needs to be taken care of, and you have not yet maxed out your insurance benefits for this year, now is the time to exercise these benefits to their fullest potential. Insurance benefits do not roll over to the following year, so let’s say you have four crowns that need to be done, and each crown costs an arbitrary $1000 (once again, the true cost of a crown will depend on the type of crown prescribed by your dentist, and the contracted fee schedule with your insurance company). Your insurance company covers crowns at 50%. This means for each crown, your insurance will pay an estimated $500, while your estimated patient portion is $500. If you have not used any of your benefits this year and your individual annual maximum is $1500, this is enough to cover three of the four crowns (insurance pays $500 per crown, so for three crowns, insurance will pay $500 x 3 = $1500). At this point, you have maxed out your insurance benefits and if you want to do the fourth crown this year, then you will pay 100% of the fee; in this case, that would be $1000. Beginning January 1, 2014, your insurance benefits renew and you will have another $1500 individual annual maximum for the year. With this fresh start, you could undergo that last crown procedure if you choose to do so and enjoy the 50% coverage by your dental insurance.
As depicted, if you need four crowns, and you end up letting your insurance benefits expire by doing nothing this year, beginning 2014, you will still need four crowns, but will only have $1500 worth of insurance benefits (the $1500 that you didn’t use this year does not roll over to the following year). Thus, we end up running into the problem of letting our hard-earned money go to waste by not exercising our insurance benefits to their fullest and will have to pay more out of pocket once the $1500 annual maximum has been reached. Drs. Nelson and Jason Hui here at Paragon Dentistry always recommend taking care of necessary treatment in a timely fashion and maximizing insurance benefits this year so that our patients can have a clean slate of full insurance benefits the following year in case any emergency dental care arises.
We hope this blog post has been helpful in explaining the way dental insurance benefits work. We want the best for our patients and want them to maximize their insurance benefits so their out of pocket costs are minimized. The end of the year tends to be the busiest for the field of dentistry because everyone is trying to utilize all their insurance benefits, so please do not wait until the last minute to schedule your treatment because appointments may be extremely limited! We would hate to see all those insurance benefits lost forever! Contact us now; we would love to take care of you and your entire family’s dental needs!
The Paragon Dentistry team would like to invite you to experience the difference at our practice while restoring yourself to optimal dental health!