How Does My Dental Insurance Work?

One of the most frequently asked questions by our patients to our Calgary dentist is how much will their dental insurance cover.  The answer to this question depends upon many variables, including what insurance company the patient has, the type of dental plan the patient has, whether there is a deductible or administration fee associated with the dental insurance plan, and the type of dental treatment the patient requires.

The amount covered by a patient’s dental insurance first depends upon the type of plan the patient has. Secondly, plans vary widely amongst dental insurance companies.  Plans within the same dental insurance company also vary widely depending upon whether it is an individual plan, whether it is an employer sponsored plan and sometimes even which plan within these types of plans the subscriber has chosen.

With the majority of dental insurance plans, the percentage of coverage depends upon the type of treatment. For instance, it is not uncommon that, for basic dental treatment, which often includes dental hygiene cleanings, check-ups, teeth extractions, including wisdom teeth, and fillings, 80% of the cost of the dental treatment is covered by the dental insurance plan.  Often, major dental work, such as dental crowns and root canals, are only covered at the rate of 50%.  Some dental insurance plans, however, cover 100% of dental treatment.  Some plans do not cover certain types of dental treatment.  Purely cosmetic dental treatments such as dental veneers or neuromodulators (such as Botox or Xeomin), for instance, are often, but not always, excluded from coverage.  Some dental insurance plans will also not cover dental implants, but again, this varies widely between dental insurance plans.  Noteworthy is that many plans will also only a percentage of the cost of the treatment up to a certain fee guide amount, which fee guide amount can also vary, depending upon the dental insurance plan.

It is also noteworthy that many dental insurance plans have annual maximums.  This is important because, although you may have coverage for a certain type of dental treatment, if you have reached your annual maximum amount allowable under your dental insurance plan, which is usually a dollar amount, you will not have any coverage for that particular treatment until your dental plan renews for the year.  Dates of renewal often correspond with the calendar year, but not always.  Other plans limit certain types of treatment such as dental scaling to a certain number of units per year, such as 12 units of dental scaling per year.  

Some patients have more than one dental insurance plan, which is often referred to as “dual” or “secondary” insurance.   Generally, the “secondary” dental insurer pays the balance or a portion of the balance remaining after payment by the patient’s primary dental insurance plan.  Depending upon the secondary insurance company’s policy, sometimes the entire balance will be paid by the secondary insurance; however, sometimes the balance will not be paid or only a portion of it will be paid if the primary insurance company has already paid the maximum that the secondary insurance company would have paid if they had been the primary insurance company.  Again, this depends upon the insurance provider and the plan itself.

Because of the many factors involved in determining whether a particular dental procedure has coverage for a particular patient, our Calgary dentist always recommends that, particularly for major dental treatment such as dental crowns and dental implants, the patient requests that a pre-determination be completed.  A pre-determination is confirmation from the patient’s dental insurance company of the amount that the dental insurance company will pay for a particular treatment.  Again, be aware that, when a pre-determination has been obtained, even this amount can change if, between the time the pre-determination has been obtained and the time the treatment is completed, there has been additional dental work completed in which case your annual maximum may have been reached, or the status of your dental insurance may have changed, for instance, if you no longer work for a particular employer.

In all instances where there is a patient portion after payment by insurance, it is the patient’s responsibility to ensure that that patient’s portion is paid to the Calgary dentist.

As you can see, dealing with your dental insurance can be complicated.  Our Calgary dentist encourages all of our patients to read their policy and bring it to their dental appointments.  We are here to help you understand and maximize your dental insurance benefits. Please call us today at 403.283.4252 if you have any questions about your dental insurance and we will do our best to help you navigate your policy so you can achieve and maintain your best oral health. Let's make your smile last a lifetime!

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