Understanding Dental Insurance & Dental Plans

An article written with Dr. Sherry Tsai

percent symbol showing how to calculate insurance copays out of pocket
No doubt about it, understanding and making sense of dental insurance can be confusing and time-consuming. Understanding the difference between a PPO and HMO, terminology such as capitation, Flex Spending, reimbursements, co-pays and limitations are enough to intimidate anyone. However, taking a step-by-step approach, dental patients can learn the difference between the various types of dental insurance plans as well as which dental plan is best suited for yourself and your family. Dr. Tsai knows that insurance companies make it difficult to understand policies and benefits but she and her team make it easy for you by being proactive with your insurance. This guide is to help you better understand your insurance plan. Though your specific details will differ, it allows you to explore and understand the limitations of dental insurance.

Because of rising health care and dental costs, a shaky economy and efforts to save money, more employers are reducing choices and benefits for employees, especially dental insurance. Patients need to take a proactive stance when it comes to researching the best type of dental insurance plan to protect them and their family. Dr. Tsai never lets insurance benefits interfere with proper and proactive dental health – your health. Though it's your dental insurance, Dr. Tsai has team members dedicated to helping you understand details of each plan. If you ever have questions about your dental coverage, please give her team a call.

What you should know about dental insurance coverage

woman holding her hand to her ear to show she is listening
Most dental insurance plans offer basic coverage called preventive dental care, including regular checkups and cleaning and prevention of gum and tooth diseases, maintenance including fillings, extractions and some major treatments. However, many plans don't cover dental surgery, dentures, or orthodontics. Why don't they cover everything? Basically, it comes down to cost. Dental insurance plans and employers don't offer full protection against all scenarios but are rather designed to offer monetary benefits that are designed to help you off-set your costs. Since employers pay the bulk of the monthly premiums, they alter plans to save themselves money, thereby passing the cost on to you. Actually, most dental plans only cover a portion of total costs of dental treatments.

Despite rising healthcare costs and standard of living increases, most insurance companies have not increased basic benefits in over two decades. This explains why most patients continue to pay what are known as co-pays. Dental insurance plans also include a deductible, which is defined as a pre-agreed upon amount of money that a patients must pay before insurance companies pay for treatments and services. Deductibles are also commonly known as out-of-pocket expenses. Patients consider deductibles and co-pays out-of-pocket expenses, as well as money paid for treatments or procedures to dental providers that aren't covered under the dental insurance policy.

Common dental insurance limitations

dental limitations
Patients should also be aware of limitations for various services found in dental plans. For example, many insurance companies require patients to wait a certain amount of time between the start of your plan (even though you are paying a monthly premium) and the time you obtain major dental care such as crowns, bridges, etc. This is called a Waiting Period and it allows the dental insurance companies to collect their money up front. Another common example is that some dental insurance companies place a limit on how many fillings, x-rays, extractions, and cleaning are allowed on a yearly basis. Be sure to ask your HR department or insurance broker about these limitations. You can also ask Dr. Tsai’s team to look up your benefits for you. She and her team want you to get all the benefits you're entitled to.

Other terms commonly found in dental insurance policies include capitation, reimbursement, and Flex Spending. Many dental providers, especially those who belong to HMO organizations, offer capitation plans. Such plans pay a dentist a set amount each month whether or not you come into their office. They also pay a predetermined amount of money for specific dental procedures: no more and no less, regardless of how much time, effort, visits or procedures a specific patient may require. These plans tend to yield the lower quality dentistry as the doctor's incentive is to not see you or perform the minimum preventative treatment possible. As a result, high quality dentists like Dr. Tsai and her team choose not to work with HMO plans.

Dental insurance plan reimbursement

doller sign symbolizing cost of dental implants
Reimbursement is a predetermined amount of money the dental provider may receive for services rendered. Some dental insurance plans require patients to pay for services rendered and then submit an insurance claim form to the dental insurance company for reimbursement, or repayment. These are typically plans that employers set up to “self-insure” their employees. You are allowed to see any provider you choose, and you pay the provider for the dental services and your employer reimburses you up to the set limit. The nice thing about these plans is the flexibility it allows – you can choose any provider you want. They also typically have fewer exceptions and limitations on procedures.

A Dental Flex Spending account is a medical or health expense account set up through an individual's bank, broker or employer. This health-related expense account may be used to meet unexpected or planned-for dental expenses. In most cases, a set amount from your paycheck is deposited into your flex account during each pay period. Similar to health savings accounts, some money placed in flex spending accounts are not subject to Social Security or income taxes. Most plans limit the amount of money that maybe deposited into such accounts on an annual basis to between $2-$3,000. However, individuals should know that unused money left in a flex spending account at the end of the year is forfeited, so its essential to use that money!

Dental PPO insurance vs. Dental HMO - Which one is best?

box of chocolates symbolizing that there are many choices of dental insurance
Dr. Tsai encourages patients to carefully read through dental insurance policies to determine maximum benefits allowed for individuals or families on an annual basis. Patients should also be aware of and understand exactly what's covered and what's not under basic dental insurance coverage plans.

Two types of plans are common these days:

PPO - stands for Preferred Provider Organization. This type of an organization is made up of health insurance providers who have formed a network of dental professionals to offer services to consumers. Dentists who belong to a PPO offer lower fees to patients. However, individuals belonging to a PPO must choose a dental provider from within the network of specific dentist offered by the health insurance company in order to save on costs. Patients can choose dentists outside of the provider network but this may change their copays. Fortunately, Dr. Tsai is one of very few highly trained dentists who have remained in network for many of the more common insurance plans.

HMO - stands for Health Maintenance Organization. Patients enrolled in HMO plans are required to choose a dental professional from within the network. Patients who use dentists outside of the network are required to pay that dentist's bill in full.
Patients should know that PPO providers are paid on a per service basis, while dentists belonging to HMOs are only paid a set fee for services, often resulting in lower quality dentistry and lab work. PPO providers are therefore able to provide much higher quality dental care and treatments. Dr. Tsai works with all major PPO plans including unions, individual plans and group or employer plans.

Millbrae Dental Care works with most PPO dental plans

Dr. Tsai and her team are available to help patients wade through all the details of your plan; from copays to deductibles and limitations. Her team has worked with almost every dental insurance plan in the bay area can can help you navigate the details while maintaining that beautiful smile of yours. Dr. Tsai is a progressive and proactive doctor who focuses on the latest methods, techniques, and tools dentistry has to offer. She is dedicated to preserving your natural tooth structure, taking care of all your dental needs in a comfortable, conservative and informative environment.

Have questions about your dental insurance plans? We can help. E-mail or call us: 650-583-5880

Dr. Sherry Tsai works with most dental insurance plans in the Millbrae, San Bruno, Burlingame, San Mateo and the Bay Area

88 Capuchino Dr.  
Millbrae CA 94030

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