Insurance FAQs

Is dental insurance a good thing?
Yes! Insurance has helped millions to achieve a higher level of dental health. But it must be used correctly. Some people believe that if they don’t have insurance that they can’t afford dental work. Some people with insurance believe that if their insurance won’t pay for dental procedures, then they must not need it, or they believe it isn’t important. Others won’t spend beyond its limitations.

THE TRUTH is that dental insurance provides help with getting dental work you would do anyway (you just budget differently). Not having insurance doesn’t make your teeth less important or necessary for health, social/career success, or self-confidence. Besides, you only get a limited amount of coverage anyway! Dental insurance is a good thing if you don’t let the insurance company make your health decisions for you, or think that without it you can’t afford dental care.

What is dental insurance?
Insurance is a way of controlling risk and protecting yourself against a financial loss by spreading the risk of loss across a large population. Common examples include auto, home and life insurance. Premium rates and costs are determined by adding up the calculated costs of benefits paid out, plus overhead and administrative costs, plus the profits desired by the insurance company. Like any other insurance, better benefits are obtained by paying higher premiums.

What will my dental insurance cover?
Unlike major medical, there is no such thing as “major dental”. Few, if any dental insurance plans are a “pay-all”. Some insurance companies pay a fixed amount, others a percentage of pre-determined limits. Any plans that claim to or actually do pay the entire dental bill can only do so because of agreements or choices that discount services, or offer low quality or cheaper treatment.

What dental services are covered? What aren’t?
Like any other insurance, your insurance coverage is only as good as the policy that was purchased. Many people are surprised to discover that many dental services are not covered. If you are dissatisfied with the amount or limits of your coverage it is important to discuss this with your employer and insurance company.

In an attempt to decrease their costs, dental insurance companies tend to reward prevention and limit reimbursement for complex or more involved care. In short, while they may pay well for wellness checkups and cleanings, they tend to discourage higher quality services. Higher quality and “major” treatment services may not be covered as well, or at all. The coverage available to you is solely determined by the profit structures of the insurance company and the quality of insurance purchased by you or your employer. Better insurance coverage costs more!

Why won’t my insurance pay more?
Unlike major medical plans which may cover complex treatment and protect against “catastrophic loss”, all dental plans have a “stop-loss” or “Annual Maximum” which typically ranges from $1,000 to $1,500 per year. This means that regardless of your need or situation, the insurance company will not pay out more to you than this annual limit. Thus there is no risk or downside to the insurance company, and it hardens or stabilizes their profits. For you, “dental insurance” equates to nothing more than having “pre-paid dentistry” which you must use or lose each year. Additionally, complex and convoluted rules and formulations for payment of benefits are created and used by your insurance company to deny, delay, and defray the reimbursement of covered services.

Do insurance companies exist to pay for dental care?
There is only one purpose for dental insurance companies – to make a profit. Ironically, while insurance premiums have steadily increased over the past 35 years, the average insurance coverage is still the same as it was 35 years ago when it started – $1000. Inflation alone should certainly have increased the available benefit to over $5,000-10,000 today. Your insurance company gives you increasingly less coverage and charges you more for it. It is why they can pay their CEOs extraordinary salaries and continue to own and acquire real estate and stock market holdings as they do.

The example I use for my patients is just look at our own Metropolitan Life building on 42and Street and Park Avenue. How did they acquire such a prime piece of real estate? By collecting premiums and delaying or denying paying benefits!

How does my insurance company make money?
Income minus overhead equals profits! In other words – Your insurance company collects the premiums, administrates the benefits plan, and makes a profit on the difference. Complex rules for annual limits (“stop-loss” maximums), utilization of services, coverage percentages, and UCR fee schedules, aid the insurance company in their quest to take in more money and give out less in the way of benefits. They are typically very slow to adopt modern treatments, they disallow alternative based therapies, they usually disallow coverage for functional based problems and they cover other high quality procedures poorly, and they use their own internal fee schedules (U.C.R. dictated by zip code geography) that are not the same as your dentist’s fee schedule, and which is determined solely on the profit motives of their company.

“Deny, delay, and defer” are watch-words that infamously characterize the insurance industry and frustrate both doctor and patient in trying to be made whole after care is rendered. Pre-authorization and pre-determination rules complicate and hinder the timely and effective delivery of care – all unnecessary and designed to delay and second-guess the doctor-patient relationship and increase the profits of the insurance company. We are all grateful for what insurance can and does afford us. All insurance companies are contractually obligated to pay benefits to which you, their insured, are entitled. The “game” lies in getting there.

Who is responsible for payment?
When you present for care and agree to treatment, you accept direct responsibility for paying the dental bill to the dentist, regardless of third-party coverage or assignment of benefits. Remember that your dentist works for you, not your insurance company. We do accept many types of insurance and we will explain your benefits to you, but for a more complete explanation we suggest you contact your plan’s benefit manager.

What should I do if I don’t have insurance, or run out of insurance coverage?
Approximately 60% of our population does not have dental insurance coverage. When it comes to their own dental needs, they simply budget their discretionary dollars so as to afford dental care. If needed care exceeds your insurance coverage (a very likely scenario) you will do the same.

It is more about what you value than the amount of money available. Proof exists in the fact that we buy cars or boats, go on vacations and travel, buy pet food, cosmetics and hair care, do recreation and dinner out (and not always at the cheapest restaurant), tobacco, alcohol, etc. – in essence, have a lifestyle – all without using insurance reimbursement to fund it. The truth is that little if any of this “lifestyle” spending is “necessary!” It is all discretionary! Unlike heart attacks and broken legs, almost all of dentistry is discretionary as well. (How many broken smiles have you seen lately?) The key is to understand and change your values, to make better discretionary spending choices, and to make it affordable with financial options – before you suffer irreparable damage.

Should I use my insurance coverage to determine my dental treatment?
In a word – “No!” It is understandable that you might want to make treatment decisions based on how much coverage you have. You may even assume that your coverage will pay for all of your costs. Regrettably, this is not the case! Just as you would never choose to leave portions of your cancer untreated, you shouldn’t choose to ignore dental decay, broken teeth, toothaches, abscessed teeth, and maybe even unattractive unflattering smiles that hurt you socially or in your career. This would be true whether you had or didn’t have third-party coverage, or had limitations of coverage therein. Your insurance company doesn’t care if you have disease or ugly! Their primary interest is not you. It is in protecting the difference between their income and their outgo. Period!

What does it mean when my insurance company tells me my dentist’s fees “exceed usual, customary and reasonable”? What is “UCR”?
It usually means that your insurance benefits are too low. Better insurance plans will often pay a higher amount. With dental insurance, you get what you and your employer pay for minus the overhead and profits of the insurance company.

“UCR” stands for Usual Customary and Reasonable. The insurance industry uses this term to try to standardize fees and to make a commodity out of professional services. They would have you believe that a dentist is a dentist is a dentist, and a crown is a crown is a crown, regardless of the training, care, skill and judgment required to accomplish it. There is no UCR fee that truly represents “usual, customary or reasonable” that isn’t created internally by the insurance company based upon its own internal overhead and profit calculations.

Will my dental insurance pay for my dental care?
Yes – up to a point. And that point is determined by the limitations and exclusions in your insurance policy, and the type of plan it is.

Why does my insurance company not pay for some procedures?
The determination of whether certain procedures are covered or not is dependant on what type of policy and how much your employer pays for it. Typically, insurance will not pay for “elective” or “functional” problems that do not have their basis in trauma or pathology. Some modern dentistry and newer cosmetic procedures are likewise not covered. The purpose of dental insurance is not to be a pay-all or make you look beautiful, but to help defray the expenses associated with prevention and minor reparative work.

What is the relationship between dental fees and insurance coverage?
When an insurance company policy states it will pay X % of a procedure, it is using its own fee schedule, not the dentists. Usually insurance companies fee schedules are lower than the dentists. These fee schedules are internal to the insurance company, are determined solely by the overhead and profit motives of the insurance company, and have no relationship with the actual fees charged by the dentist. Additionally, these fee schedules will vary from area to area, despite the uniformity of the standard-of-care in our country. Insurance companies would have you believe that you can get something for nothing.

What’s the best way to deal with problems related to my dental health benefits?
You are best advised to discuss issues that may arise with your employer or his human resources manager, and/or your labor union. Remember that the “richness” of your benefits package is determined by how much is paid for the insurance policy in the first place, as well as the internal policy rules that regulate the ease and availability of getting the benefits paid out.

What are the different kinds of insurance plans?

There are three main types of insurance:

  1. Traditional indemnity insurance plans
    2. Preferred provider organizations (PPO)
    3. Health maintenance organizations (HMO)

Traditional indemnity plans offer the greatest freedom of choice in services and health care providers. PPOs and HMOs, sometimes referred to as “alphabet” and “managed care” plans, frequently result in less freedom of choice for the patient , fewer available appointments, cheaper dental materials and lab quality, and have more restrictions and exclusions in what they cover.

Do I have to go where my insurance company says? Am I required to see a certain dentist?
No! But if you have a closed or restricted plan, you may not receive the meager benefits purchased unless you see their preferred doctors who have agreed to discount their services and who offer cheaper care. If you have one of these plans and if you decide you want better care for yourself or your family than what your insurance policy will pay for, you are always free to choose higher levels of services and higher quality of care from private fee-for-service offices such as The Center For Dental Health. Traditional indemnity insurance plans are representative of the better plans and do not have prohibitions or restrictions on who you may or may not see.