Insurance plans vary depending on your employer and insurance company. The plan you have is an agreement between you, your employer and the insurance company and is by no means restricted to the following general summary.

Insurance categories

Most insurance plans group dental insurance into three categories:

• Preventative and Diagnostic – Usually covered at 100% and includes cleanings and exam twice a year, a set of bitewing x-rays once a year, panoramic/full mouth x-rays once every 3-5 years. For children under the age of 14, fluoride treatments and sealants may be covered also at 100%.
• Basic – Usually covered at 80% and subject to a once a year renewable deductible similar to car insurance. The deductible usually ranges between $25 and $100 per year per person. Basic procedures often include fillings, root canals and oral surgery.
• Major – Usually covered at 50% and also requires a deductible. Major procedures are prosthetic and include dentures, crowns, bridges and implants.

How your insurance and deductible work

Under most insurance plans, preventative and diagnostic is covered at 100% with no deductible required. Insurance companies are willing to pay a 100% of Preventative and Diagnostic because they realize that if they catch a problem such as a cavity early it will cost them a lot less than if it spreads and you have to have major work done. By paying for x-rays once a year and cleanings twice a year, you statistically will have a significantly less chance of developing any serious problems. As the treatment expense increases from preventative and diagnostic to major the amount your insurance will cover drops. Also, basic and major services usually require a deductible before a calculation of benefits is determined. The following is an example of the cascading payment of insurance (the following prices are not actual prices of the procedures listed):

• Cleaning and Exam - $100 (not an actual fee)
• Root Canal - $500 (not an actual fee)
• Crown - $800 (not an actual fee)

Assuming your insurance plan is similar to the one above, they should cover 100% of the cleaning and exam. The root canal is covered under basic at 80% and will be subject to a deductible. This works in the following manner for a $50 deductible:

• $500 - $50 = $450
• 80% of $450 is $360

Note that the deductible is subtracted off the charge before the insurance portion is calculated. The patients responsibility in this case would be $500 - $360 = $140. Your deductible is a one time per year charge. This means that if a patient pays their $50 deductible on a root canal then it won’t be calculated into another procedure for that calendar year. For instance, if a patient received the root canal above and then needed a crown, which is covered under major at 50%, the patient’s portion of the crown would be $400 if the total fee is $800.

Yearly Maximum

A yearly maximum is the maximum amount of money that an insurance company will spend on you per year. Yearly maximums usually range from $1000 to $3000 and are based on the agreement between your employer and the insurance company. Most yearly maximums renew each year beginning January 1st, but it is also not uncommon for a plan to renew on the employee's hire date. If you do not use your entire maximum for the year it does not roll over to the following year. Let’s say Joe has a yearly maximum of $1500 and Joe uses up $1000 in 2006. When January 1st comes along, he will have $1500 for 2007 and not $2000. Yearly deductibles also renew on the same date as your yearly maximum.

Once diagnosed for treatment, it is recommended that you have the problem treated as soon as possible, but if you need to have a lot of work and can’t afford to have it all at once, you can utilize your benefits for two years. For instance, if you had to have four crowns done but your insurance maximum will cover only a percentage of two of them, you can have two done in 2006 and the other two done in January 2007.

Reasonable and Customary Rates

If you have ever talked to your insurance company about dental benefits, you may have heard them say that payments are based on reasonable and customary rates. This means that your insurance company has a fee schedule for your plan. The fee schedule means that they will pay benefits based on the above outline but cap the price of a procedure. For instance, if your plan says it will cover a cleaning that costs $50 at 100% but pays only $40, they have a fee cap on your plan. Unfortunately this means that you are responsible for paying the remaining $10 even though your insurance says they will pay 100% of a cleaning. Fee caps vary from insurance plan to insurance plan and company to company. The amount of money your employer is willing to pay towards your dental benefits will determine the appropriate fee caps for your plan. It is a good idea to call your insurance company and request a fee schedule for your plan if you do not have one. Fee schedules are a statistical way of calculating how much an insurance company can allocate to certain procedures without losing profit based on the amount of money they receive from an employer.

For example, let’s say company A and B both have MetLife as their dental insurance company. If company A pays $50 per person per month for dental and company B pays $75, company B’s dental plan may cover a cleaning up to $60 while company A’s will cover only up to $40 even though they have the same insurance company. If the dental office bills MetLife $50 for a cleaning, the office will receive $50 for company B employees and $40 for company A employees. If the price of the cleaning were $70, then company A’s plan would pay $40 and company B’s would pay $60.

Insurance companies do not release fee schedules to dental offices; otherwise they risk losing hidden money such as in company B’s plan. MetLife, in the illustration above, will not send a dental office $60 for a cleaning if they submit one for $50 even if the plan allows up to $60. It is nearly impossible for a dental office to give you an exact amount that your insurance company will pay, because we do not have access to fee schedules.

As a courtesy to our patients we will file your insurance claim for you.
We are in-network with the following insurance companies (please call if you do not see your provider listed):

• Blue Cross Blue Shield of NC incl. Federal Plan
• United Health Care
• Cigna PPO
• MetLife
• Connection Dental
• Ameritas
• Aetna PPO
• Guardian
• DHA
• Dentemax
• Delta Dental

We are not a DMO or a DHMO provider.
Unfortunately at this time we do not participate in the Medicare/Medicaid Program.