Understand Your Dental Insurance

Understand your dental insurance with a tooth.

Understand Your Dental Insurance

Understanding dental insurance is not an easy task. A new year has started, so let’s start it off on the right foot when it comes to your dental insurance. Typically, when looking at your benefit booklet, claims or estimates there are many things that may not be clear. The dental/insurance jargon is heavily sprinkled throughout those documents and may not do you any favours when you’re trying to determine what you are actually covered for. Here is a simple list of definition/explanations that may her you understand your dental insurance.

Annual Maximum – Most dental plans have an annual dollar maximum. This is the maximum dollar amount a dental benefit plan will pay toward the cost of dental care within a specific benefit period (usually January through December). Anything above and beyond, you are responsible for paying the difference.

Benefit Period – Dental benefits are calculated within a “benefit period.” The benefit period typically is for one year, but not always a calendar year. This all depends on your plan and your insurance carrier.

A man filling out a dental insurance claim form on a desk.

Categories of Coverage – Many dental plans offer three categories or categories of coverage – often with different reimbursement levels for each. Each class provides specific types of treatment and those treatments are typically covered at a certain percentage. Each class also specifies limitations and exclusions. The typical classes are:

  1. Basic Coverage: this is basic dental care and typically includes the following, but it will differ from one dental plan to another.
    • Ongoing care and maintenance of teeth, roots and gum
    • Diagnostic services – exams, radiographs, X-rays and test
    • Preventative treatment – polishing, scaling, oral hygiene instruction, pit and fissure sealants, and space maintainers
    • Minor restorations – fillings, prefab crowns for primary teeth, and other services completed in conjunction with minor restoration
    • Endodontics – root canal therapy
    • Periodontics – treatment of gums
    • Denture maintenance – relines and rebases
    • Oral surgery – removal of teeth
    • Adjunctive services – anesthesia, medications and pain relief
  2. Major Coverage:
    • Crowns and onlays
    • Dentures and bridges
    • Related items such as posts, pins and denture-related surgery
    • Replacements when the existing appliance is five or more years old
    • Appliance maintenance – denture relines and rebases, denture or bridgework repair Related items such as posts, pins and denture-related surgery
  3. Orthodontic coverage includes:
    • Ortho-exams, X-rays, diagnostic radiographs and casts
    • Braces and retainers

A hand writing the word co-payment on a white board to help you understand your dental insurance.

Co-payments – A co-payment is the portion of the dental treatment that you are responsible for paying. Some insurance coverage is better than others. Some cover 100% and others only cover 80% for Basic services. Some cover 50% for Major services. Regardless of the coverage, you are responsible for paying the remainder of the fee. What is interesting to know is that failure to collect or “write-off” the co-pay of a patient is against the law. We don’t make you pay it because we want to, we are legally obligated to collect the money. Visit the Canadian Dental Association here for more information about your co-pay.

Pre-determinations/Estimates: This simply a hypothetical claim that we send to the insurance company to get an estimate of the coverage you have for your required dental work. We can ask for estimates for anything from dental cleanings to complicated dental surgeries. The trick here is that the insurance company send the estimate to you, not to the dental office. So we rely heavily on your help to bring us the estimate once you get it. This is why you will get a phone call from us, several weeks after the estimate was sent to see if you have heard back from your insurance.

Privacy Policy – This is something that has changed drastically in the recent years when it comes to dental insurance. We are no longer able to call your insurance company to find out whether you are covered for something or to check how much coverage you have left. The insurance companies (due to privacy laws), will no longer release this information to any dental office. This is why sometimes it is your responsibility to find out what you are covered for and how much you have left. In these cases, sending an estimate is very beneficial (but timely).

Hopefully this little guide to insurance basics helps you understand how dental insurance works. It’s a complicated thing and with the thousands of insurance companies out there, it is nearly impossible to know them all…although we try!! 🙂 If you have any questions, please email or call us and we will be happy to help.

For more information about dental insurance visit the Canadian Dental Association.

Dr Christopher Sims
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