What does my dental insurance cover?
What may be considered under my medical insurance?
What procedures are not likely to be covered by dental / medical insurances?
Can I get insurance before my planned oral surgery?
What are deductibles, maximal allowable, annual limits, percent coverage, etc?
How do in-network and out-of-network benefits differ?
What does my dental insurance cover?
If you have a PPO dental insurance plan, it can offer benefits for teeth extractions (including wisdom teeth), anesthesia, and some biopsy procedures. Simple bone-grafting procedures may be covered under some plans. We are not member of any HMO plans and can not accommodate them.
What may be considered under my medical insurance?
Biopsy procedures, traumatic injuries, and some bone grafting procedures for reconstructive purposes may be considered under medical insurances. Dental implants may also be considered if tooth loss was result of trauma or significant pathology such as cysts. Corrective jaw surgery (orthognathics) is also considered under medical insurance although many have specific exclusions.
What procedures are not likely to be covered by dental / medical insurances?
Dental implants, some bone grafting procedures, cosmetic procedures, and some corrective jaw surgeries are considered elective and therefore not likely to be covered by either dental or medical insurances. You may contact your insurance company for specific rules regarding coverage for these procedures.
Can I get insurance before my planned oral surgery?
You may choose to obtain dental or medical insurance for your desired oral surgery, but make sure to inquire about specific benefits for such procedures, exclusions, and waiting periods for pre-existing conditions. In most situations, insurance does little to help patients with their oral surgery cost.
What are deductibles, maximal allowable, annual limits, percent coverage, etc?
Deductibles are a fixed amount that you must pay out-of-pocket before benefits are considered. Depending on your specific plan, this may be $50-$250 for some dental insurances or as high as $2500 for some medical insurances.
Maximal allowable, also known as usual and customary rates (UCR), refers to a fixed amount that your insurance company has allocated for a specific procedure, based on the procedure itself and zip code of the provider. For example, the maximal allowable for a tooth extraction may be $300. Your insurance company will base this amount for calculation of your benefits and may reimburse 50 to 100 percent of it based on your plan type. Any amount of the actual fee for the extraction not covered or above the maximal allowable will be your responsibility.
Annual limits: Dental insurances have maximal annual limits for benefits. The majority are $1,000 to $1,500 per year, per individual, but may be as low as $750 or as high as $5000 (for more premium insurance types). Any dental claims submitted are considered as long as you have available funds in your annual limit. These benefits typically expire at end of calendar year (usually Dec. 31st) and are not transferable.
Percent coverage: The benefits for each procedure may be 50 to 100 percent of the UCR amount. The majority of extractions and anesthesia services are covered at 80% of the UCR. Consultations and x-rays are often covered at 100% of the UCR. Some insurance companies put limitations on panorex x-rays to one every three years.
How do in-network and out-of-network benefits differ?
Our office is not a member provider with any insurance plan, however we can accommodate many insurance plans as out-of-network provider. Many ask what that means to them and their out-of-pocket expense?
In-network providers follow the UCR value as the maximum they can charge you, while out-of-network providers can charge you the difference between their fee and the UCR. Here are some facts important to note:
- The difference in our fees and the the UCR for most insurance companies are relatively small and make little difference in your out-of-pocket expenses.
- Deductibles, annual limits, and percentage of the coverage remain the same whether you see an in-network or out-of-network provider, and therefore makes no difference.
- Procedures like dental implants and bone grafting procedures are considered elective and therefore not covered, whether you go to an in-network or out-of-network provider.
- If you have significant oral surgery needs and the fees go beyond your annual limits (example: $2,500 fees for your oral surgery needs with $1,000 available), you remain responsible for the difference ($1,500 in this example) and in- or out-of-network status makes no difference.
- If you have minor oral surgery, the difference between in- or out-of-network providers is negligible.
Considering all the facts, it’s best to choose an oral surgeon based on your dentist’s recommendations, your trust and confidence rather than what your insurance company dictates.