Dental insurance can be extremely confusing for many patients, for a variety of reasons. This often leads to patients not taking full advantage of a policy they are paying a significant amount of money for each year. This can also lead patients to postpone necessary treatment, which results in “small” issues becoming significantly larger(and more expensive) ones. So, how does it all work? Dental insurance has many significant differences from medical insurance, and we will review some of the good and the bad of obtaining dental insurance. Let’s compare…

Many policies are written in such a way that they allow patients to seek preventative care twice a year…this has encouraged millions of people to seek out care where they otherwise may not have. This is most certainly a good thing. The downside to this? Some patients require more frequent visits than two times a year(a number that was created based on a toothpaste commercial many years ago!). However, their insurance often does not provide benefits for these additional visits, so patients either refuse them or perceive them as “not necessary.” The other catch is that many policies are very strict on the dates of these visits…for example, on a certain policy that allows a patient to come in every 6 months, if that patient comes in even one day early, they will refuse to cover the appointment, and the patient will be responsible for any expenses.

Dental insurance often encourages patients to seek care from specific contracted providers, which results in a significant savings to the patient, another excellent attribute. However, often times patients wait until they obtain dental insurance to seek out these providers, expecting their dental insurance to work in a similar fashion to their medical insurance. Countless times we will hear patients say “I have known I needed work for a long time, but I wanted to wait until I had insurance.” A logical thought process, but with how dental insurance works, not necessarily a great plan. Why? Well, let’s discuss how these policies work…

With medical insurance, there is generally a deductible, co-pay, and an out-of-pocket maximum that the patient is responsible for…after that, medical insurance covers the rest. So, when a patient needs a lot of medical attention, having insurance is critical.

With dental insurance, there is often a deductible and co-pay; however, that is where the similarities end. Dental insurance has an annual maximum the insurance company will pay…after that, the patient is responsible for the rest. This maximum has not risen significantly for many years, with numerous policies putting a cap at $1000-$1500. For a patient with minimal dental needs, this is usually not too much of a concern. However, if a patient needs more extensive treatment(crowns, extractions, implants, root canal therapy, gum surgery), they often reach this maximum very quickly, and despite all the premiums they have paid for their dental insurance, they are on the hook for any other treatment required. Once that maximum is reached, it does not reset until the next benefit year.

Finally, there is the question of frequency…meaning, if work is done on a specific tooth, often times dental insurance companies will not allow more treatment on that same tooth for 5, 7, even up to 10 years! The trouble with that is the mouth is a dynamic environment…teeth can break, restorations can break, decay can develop-basically, life happens. This is another significant difference between medical and dental insurance. With medical insurance, generally speaking, if a patient breaks his or her leg and has it repaired surgically, and then two years later they break the same leg, medical insurance will cover the second procedure. With dental insurance, if someone has a dental crown placed on their front tooth, and then two years later they fall and chip that crown, the insurance will generally not cover a replacement, leaving the patient responsible for the entire cost of the procedure.

So, hopefully this helps explain some of the differences between medical and dental insurance. Due to the limitations, many people refer to dental insurance as a dental “benefit” instead of insurance. The real moral of the story? Understand the policy you are signing up for, or reach out to your dental office for help understanding it. If you do that, insurance can be a nice benefit. However, if you don’t understand your policy, that is where surprise expenses can arise, and nobody enjoys that!

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