Insurance FAQ

What's the difference between dental insurance and health insurance?

At Reston Sunrise Dentistry we believe that it is important for our patients to realize that dental insurance is very different from health insurance. Health coverage is often referred to as "true insurance," while dental plans may more accurately be called "benefit plans."

The goal of regular health insurance is to defray the cost of emergency or serious medical expenses. Dental health plans, on the other hand, focus on prevention. Patients receive the most attractive discounts on regular dental hygiene visits. But patients should expect to pay more for expensive restorations, that's we we always encourage our patients to keep up on their routine general dental care.

Almost all dental procedures are considered elective. That means that they are not strictly required for health; in other words, you are not likely to die from dental disease. (Physicians consider things like cosmetic surgery to be elective.) Though good oral health is a critical part of overall health and wellness, insurance companies view dental procedures quite differently than, for example, surgical interventions.

For example, if you fall off a building and require $50,000 of medical care, your health insurance will probably cover the vast majority of that. However, if you've neglected your dental health for many years and want $50,000 of restorative dentistry, your dental insurance will cover only a small portion of that. Since dentistry, especially cosmetic dentistry, is considered elective, insurance companies tend to view it as more akin to cosmetic surgery than setting a broken bone.

How does dental indemnity insurance work?

A dental indemnity insurance plan is the option most like "true insurance" - that is, it is most similar to traditional health insurance plans. It is a fee-for-service plan that does not use networks, so patients can visit any dentist. After you have paid your deductible, the insurance company will pay all or part of your "usual and customary" dental care costs.

"Usual and customary" is a very important bit of wording! It is the insurance company, not the individual dentist, who decides what are "usual, customary and reasonable" rates using a UCR fee schedule. If your dentist charges more than what the insurance company has determined is "usual and customary," you will usually be responsible for paying the difference. Fee schedules can vary significantly by region and by insurance company.

Dental insurance programs offer different levels of coverage for different types of dental care. A program's coverage is often expressed as three different percentages. For example, a 100-80-50 dental health plan would cover the following:

• 100% of preventative and diagnostic services (cleanings, regular exams, and x-rays)
• 80% of basic dental care and restorative services (basic dental fillings)
• 50% of major services (bridges, crowns, dentures, etc.)

Dental insurance plans also have annual maximum benefits, usually between $1,000 and $2,000. This is the maximum amount the insurance company will pay out for dental care in one calendar year. Since complex dental restorations can cost thousands of dollars, even patients with insurance can end up paying for much of their care.

What's managed care dental insurance: PPO and DHMO?

A dental PPO ("preferred provider organization") is analogous to a medical PPO. Patients are free to see any provider within the insurance company's PPO network. Participating dentists have agreed to discounted rates negotiated by the insurance company. This insurance follows a traditional "fee for service" model, meaning that the dental practice receives a fixed fee for each procedure performed.

With some forms of PPO dental insurance, you can see any dentist you like. However, you will receive a better deal when you visit a network dentist than a non-participating dentist. Some dentists will participate in PPO plans but avoid HMO ones.

A dental HMO (DHMO, for "dental health maintenance organization") follows the medical HMO model. Patients are assigned to a primary provider. This kind of plan is also known as a dental capitation program or a "cap" program. Unlike PPO programs, dentists do not receive fee-for-service payments. Instead, the dentist receives a set allowance per patient per month, regardless of how much or how little care that patient requires. This allowance is called a "cap."

If you have HMO dental insurance, it will only cover visits to in-network providers. If you see a dentist or dental specialist outside of the HMO network, you will foot the entire bill yourself.

A dental EPO ("exclusive provider organization") works much like an HMO, at least from a patient's perspective. Your treatment will only be covered if you see a dentist within the insurance provider's EPO network. Participating dentists are paid per treatment, unlike HMO dentists who receive a fixed monthly payment per patient.

Direct reimbursement (DR) is a fee-for-service plan that is self-funded by the patient's employer. Employees are free to see any dentist they wish. Rather than paying monthly premiums or caps, employers pay a portion of each dental treatment received.

What about dental discount plans?

Dental plans are different from dental insurance, a fact that can be easy for consumers to overlook. Dental plans (also known as dental discount plans or dental referral plans) are different from dental insurance. Though it's possible to have both, most people have only one or the other.

These plans are essentially discount clubs. You pay a monthly or yearly membership fee and get a discount on your dental work from participating dentists. (This discount can vary greatly, but is often around 1/3.) Unlike with insurance, there are no claims forms for you or your dentist to fill out.

While most people who have dental insurance are insured through their employer, this not always the case with dental discount plans. Individual dental discount plans tend to be competitive with employer plans.

How about orthodontic coverage?

Not all dental insurance plans cover braces and other orthodontic work; orthodontic coverage is often separate from overall dental coverage. If you or your child will want or need orthodontia, this sort of coverage can save you a lot of money.

Without insurance, teen braces can be expensive. (The average cost of braces treatment tends to be about $5,000.) You can call your insurance company to see if your plan covers orthodontic treatment, and if so, how much they will pay for. If your insurer does not cover braces, you may be able to purchase an orthodontic benefits plan separately.

How do I get my dental treatment covered?

If you need significant dental work, you'll want to start by asking Dr. Pham for a treatment plan. This document outlines what you need, how much it will cost, and how long it might take. Once you have a treatment plan, you can check with your dental insurance company to see how much they will cover -- that is known as a benefit estimate or predetermination of benefits. (At Reston Sunrise Dentistry, we may even be able to contact the insurance company on your behalf.) This will help you decide if you are financially able to go ahead with the full treatment plan.

Even if it seems too expensive, Dr. Pham may still be able to work with you to develop a plan that will be both affordable and successful. This is often done by breaking treatment up into stages that are spread out over time. For example, if the second stage of your treatment occurs in the following calendar year, your benefits will have renewed. That way, your insurance will cover a greater portion of the cost of treatment.

Your treatment plan may include both recommended treatment and any lower-cost alternatives that may be available to you. While the highest-quality and most permanent dental restorations will cost the most, affordable dentistry offers more options, lots of dental problems can be solved in different ways. Many insurance companies will only cover the least expensive alternative treatment (LEAT).

For example, let's say you're missing a tooth. The best replacement tooth that money can buy is a dental implant covered with an artificial tooth. However, dental implant surgery is costly, and healing takes several months. A dental crown, on the other hand, might need to be replaced eventually, but is far more affordable.

At Reston Sunrise Dentistry we're committed to working closely with you and your insurance company to develop a comprehensive treatment plan that will be both good for your oral health and kind to your bank account.