“At Winnipesaukee Dental, we believe your dental health decisions should be made between you and your dentist, not dictated by insurance limitations. Navigating dental insurance can feel like deciphering a secret code. Misconceptions and confusing jargon often leave patients wondering what’s truly covered and what’s not. We believe in empowering you with the knowledge to make informed decisions about your oral health. Let’s debunk some common dental insurance myths and reveal the facts.”
Fiction: “My dental insurance covers everything.”
Fact: This is perhaps the biggest misconception. The current way dental insurance is designed is to assist with costs, not eliminate them entirely. Unlike medical insurance, dental insurance does not provide protection against unexpected or unaffordable costs. Medical insurance often pays a large portion of expenses after a deductible or co-pay has been met, and even those plans come at great costs now, often with $7,000 or more in deductibles. Dental insurance, on the other hand, was designed to be only an aid or supplement to help with your dental care. Most plans have:
- Annual Maximums: A cap on the total amount they’ll pay in a year.
- In 1965, dental insurance benefits typically paid $1000-$1500.
- A dental crown was, on average, $226 in 1965. A dental cleaning was around $15.
- Today dental insurance benefits typically pay $1000-$1500.
- A dental crown today based on NH statewide average, $1575. A cleaning today based on NH statewide average is $129. A crown today in our practice is $1570 and a cleaning is $126.
- If the annual maximum in 1965 had increased with inflation, you would have on average $10,000-$15,000 in coverage!
- If the cost of a crown had increased with inflation it would be on average $2,279 and a dental cleaning would be $151.
- In 1965, dental insurance benefits typically paid $1000-$1500.
- Coverage Percentages: They typically cover a percentage of costs, not the full amount (e.g., 80% for preventive, 50% for major procedures). This remains the same as it was in 1965.
- Exclusions and Limitations: Certain procedures, materials, or frequencies may be excluded, based on what the person paying for the plan decides (typically an employer who is buying the plan).
Fiction: “If my dentist is in-network, everything will be cheaper.”
Fact: While in-network dentists have negotiated rates with your insurance company, it doesn’t guarantee the lowest out-of-pocket cost.
- “Reasonable and Customary” (R&C) fees: Even in-network, if your dentist’s fees exceed the insurance’s R&C for a procedure that is not a plan benefit, you’ll pay the difference. The insurance company decides the R&C rate, it is not reflective of the actual price charged for the procedure. For example, in our area the R&C rate for a crown is $1195, while the average fee in our area for a crown is $1501, the R&C rate for a cleaning is $89, while the average fee in our area is $127.
- Treatment limitations: In-network dentists may be limited by what the insurance company dictates as “necessary” care, which may not be the optimal treatment for you.
Fiction: “Preventive care is always 100% covered.”
Fact: While preventive care (cleanings, exams) is often covered at a higher percentage, there can still be limitations.
- Frequency limitations: Some plans, picked by your employer, only cover two cleanings per year, even if your dentist recommends more to prevent tooth loss due to periodontal conditions.
- Specific procedures: Some preventative procedures may not be covered at 100%, sealants to prevent decay are typically not covered past a certain age dictated by the insurance company.
Fiction: “Cosmetic procedures are always covered.”
Fact: Cosmetic procedures (teeth whitening, veneers) are almost always excluded from dental insurance coverage.
Fiction: “If my insurance denies a claim, there’s nothing I can do.”
Fact: You have the right to appeal denied claims.
- Request an explanation: Ask your insurance company for a detailed explanation of the denial.
- Gather documentation: Provide supporting documentation from your dentist, such as treatment notes and X-rays. Even then, your insurance may say they don’t cover the procedure.
- Follow the appeals process: Follow your insurance company’s appeals process.
Fiction: “Dental Insurance is designed to cover all of my dental needs.”
Fact: Dental insurance, as stated above, is designed to help offset some of the costs associated with dental care. It is not designed to cover all of your dental needs.
Empowering Yourself with Knowledge
- Read your policy: Carefully review your dental insurance policy to understand your coverage, limitations, and exclusions.
- Ask questions: Don’t hesitate to ask your dentist and insurance company about your coverage and potential out-of-pocket costs. As we are a fee for service practice, you will always know the full cost ahead of time.
- Request pre-authorization: For major procedures, ask your dentist to submit a pre-authorization request to your insurance company to determine coverage before the treatment. This will delay your treatment, buy is helpful if you are concerned with how much you will be reimbursed.
- Keep good records: keep all of your statements, and EOBs.
Our Commitment to You
At Winnipesaukee Dental, we’re committed to transparency and patient education. We’ll help you navigate the complexities of dental insurance, provide detailed invoices, and assist you with claims. We believe in providing the best possible care, regardless of insurance limitations.
We hope this blog post has helped you separate fact from fiction. If you have any questions, please don’t hesitate to contact us.
