Working With Your Dental Plan

Understanding Your Dental Insurance


The world of insurance can become very confusing at times. At Acosta Dental Arts, PA, we aim to keep matters as simple as possible for all of our patients. We guide every patient through the process of how dental insurance works; by making it easily understood, we can avoid any confusions and misunderstanding.

Common questions and answers from our patients that you may find useful.

Q: Do you accept my insurance?

A: For your benefit we have compiled a list of all the insurances that we collaborate with (listed on the right hand side). If your insurance name does not appear on this list, feel free to give us a call at (561) 622-0301 and we can verify if your insurance can be accepted or not. Confirmations will be provided in advance before any treatment is rendered.

As of date, these are the following insurances that we do not accept:

  • Any dental HMO or DMO
  • Medicare
  • Medicaid

For patients with dental HMOs, you may upgrade to a dental PPO which will give you additional dental benefits. To upgrade to dental PPO, contact your human resources department at work or your individual dental broker agent.

Please know that we are currently treating many dental HMO, Medicare, and Medicaid patients as we have many ways to help our patients with various dental payment plans.


Q: How does my dental insurance work?

A: Dental insurance is completely different than medical insurance, functioning in very different manners. Most dental insurances have a yearly maximum (typically about $ 1,000 to $2,500 per year on average). There is an annual deductible of generally $25 to $75 to satisfy before benefits can be attributed.

Dental insurance benefits are divided into three different categories: Preventive, Basic and Major.

Preventive: are complete, routine, or emergency examination, different types of X-rays, and basic regular adult and children cleanings. Preventive categories are typically covered by insurance between 90 to 100 % – This means that you will have to pay between 0 to 10% for any preventive visits.

Basic: can be a specific set of X-rays (Full Mouth Series), white composite fillings, bondings, some dental extractions, and gum treatments (Periodontal procedures). The dental insurance typically covers 60% to 80% of basic categories – this means that you will have to pay out of pocket the remaining 20% to 40%.

Major categories: can be specific surgical extractions (like wisdom teeth extractions), crowns, bridges, dental implants (implants may not necessarily be covered on your specific plan), dentures, partials, and porcelain fillings (onlays). The dental insurance typically covers 50% to 65% of any major category procedure, this means that you will have to pay the remaining 50 to 65% out of pocket.


Q: If I don’t use my benefits this year, do I get to keep it next year?

A: No – this is actually the biggest secret that insurance companies do not want you to know. If you do not use those benefits this year, those benefits are gone forever. They do not roll over to the next year. By not taking full advantage of these benefits you may very be well throwing away thousands of dollars. Since you are paying a monthly premium for these benefits, you have the right to use these benefits to their entirety within each year. The cutoff date is typically, but not necessarily, December 31st of each year for most dental insurances.

Many patients believe they are saving money by waiting until December before starting treatment. This is absolutely not true. Most dental practices observe holidays such as Christmas and New Year’s Eve so there is no guarantee that you will find an appointment time for your dental treatment. That is why at times it may take up to three months to even have a dental appointment in some dental practices.

The very best way to fully take advantage of your dental benefits is right from the start. Call us at 561-622-0301 to find out how you can save money today by taking advantage of your dental insurance.


Q: What is indemnity Dental Plan? What is a PPO? What is an HMO?

A: Dental insurance is a type of health insurance designed to pay a portion of the costs associated with dental care. There are several different types of individual, family, or group dental insurance plans grouped into three primary categories: (1) Indemnity (or sometimes called: true dental insurance or free choice of dentist) that allows you to see any dentist you want who accepts dental insurance; (2) Preferred Provider Network dental plans (PPO); and (3) Dental Health Managed Organizations (DHMO) in which you are assigned to an in-network dentist and/or in-network dental office and use the dental benefits in that network.

Generally dental offices have a fee schedule, or a list of prices for the dental services or procedures they offer. Dental insurance companies have similar fee schedules which are generally based on Usual and Customary dental services, an average of fees in your area. The fee schedule is commonly used as the transactional instrument between the insurance company, dental office and/or dentist, and the consumer.

Indemnity Dental Insurance Plan: This plan may be helpful when you want to stay with your dentist and he/she does not participate in a dental network. By the very nature of this plan the insurance company generally pays the dentist a percentage of your services according to the policy you purchased. In addition you will want to review the co-payment requirements, waiting periods, stated deductible, annual limitations, graduated percentage scales based on the type of procedure and/or length of time you have owned the policy prior to starting your dental work – We accept all indemnity dental insurance plans.

Dental Health Managed Organization (DHMO): When a dentist signs a contract with a dental insurance company that provider agrees to accept an insurance fee schedule and give their customers a reduced cost for services as an In-Network Provider. Many DHMO insurance plans have little or no waiting periods, no annual maximum benefit limitations, while covering major dental work near the start of the policy period. This plan is sometimes purchased to help defray the high cost of the dental procedures. Some dental insurance plans offer free semi-annual preventative treatment. Fillings, crowns, implants and dentures may have various limitations.- We currently do not participate in any DHMO plans. We believe that participating in HMO dental plans lessen the quality dental and individual care that Dr. Acosta wants to provide to his patients.

Participating Provider Network (PPO): Depending on your specific plan, the PPO works similar to a DHMO while using an In-Network facility. However, it allows you to use an Out-of-Network or Non-Participating Provider. Any difference of fees will become the financial responsibility of the patient unless otherwise specified in your dental policy. As noted, some dental insurance plans may have an annual maximum benefit limit. Thus, once the annual maximum benefit is exhausted any additional treatments may become the patient’s responsibility. Each year that annual maximum is reissued. The reissued date may vary as a calendar year, company fiscal year, or date of enrollment based on your specific plan.

The enrollment process varies but often members are assigned an identification or policy number. When dental treatment is rendered a claim for services is filed with the dental insurance company. For your convenience most claims processing is handled directly by our dental office.


Q: Why do I have to pay for my cleaning appointment? My insurance tells me that all my cleaning are covered at 100%?

A: Most dental insurances will cover routine dental cleaning (ADA code D1110) at 100%. It is also a great sales pitch from the insurance company to say to future members that they do cover cleanings at 100%. However, dental cleaning is a very loose term and can be easily misinterpreted and misunderstood by the patient.

If you have not had a cleaning for more than one year, you may be subject to periodontal disease or gum inflammation. Early signs of gum disease can be, but not limited, to chronic bad breath, bleeding upon brushing, flossing, and during gum examination.

There can be signs puffiness or inflammation and tooth bone loss around the gum lines, or gum recession (shrinkage of the gum). These symptoms can also be present due to hereditary reasons or current personal lifestyle (smoker, caffeine drinker, refined sugar consumption, more exposed to stress than usual, etc).

Routine dental cleanings do not address the problems associated with gum disease. If you are in need of a gum treatment, most dental insurance cover about 50 to 80% of this particular treatment. A routine dental cleaning cannot be taken in place of a gum treatment.

At the time of your first visit, Dr. Acosta will examine your gums to appropriately determine if you are a candidate for routine dental cleanings, or if you will be in need of a particular gum treatment.


Q: Why do I have a bill after you told me how much my insurance will pay?

A: We have an in house expert who has dealt with insurancea for more than 15 years. Our dental insurance Queen, Jessica Morgan, knows everything that has to do with dental insurance. She has a very specific form and spends about 30 minutes of her time with your insurance company to go over each dental coverage and procedure (time doesn’t include hold time or leaving messages). Her goal is to minimize your out of pocket cost while helping you maximize your dental insurance without you even lifting a finger.

However, even after due diligence, it may happen that the dental insurance covers less or occasionally none of what they say they were going to cover. This is why all insurance coverage’s can only be an estimate.

We know how upsetting it can be to receive a bill after the payment of your initial estimated co-payment. Unfortunately, that is the nature of dental insurances. All fees are the sole responsibility of the patient. If there is a balance after insurance payment, we usually send a counter claim letter, and try to dispute the non-payments on your behalf. We will do so for 30 days. If the counter claim still does not work, you will be billed for the balance on your account. You are more than welcome to then try to contact your insurance to contest charges not covered.

At times, it may happen that insurance covers more than we have estimated. If there is a credit on your account, we will remit a refund or keep the credit for any future or immediate procedures that you may need. The choice is yours.


Q: I don’t have insurance, could you recommend one to me?

A: Here, you will find the list of all major insurance carriers. But the easier way to get dental insurance is to either contact your Human Resources department at work, or to contact an insurance broker agent by using Google to find a broker based on your city or zip code. If you do decide to go through a broker, make sure to receive 2 or 3 different quotes from different brokers.

If you have narrowed it down to two insurances and you are still uncertain of which one to take. Give Jessica a call at (561) 622-0301 and she will be more than provide you with assistance.


Q: My dental insurance downgrades some dental procedure. What is that mean?

A: A downgrade simply means that instead of a specific procedure, your insurance will downgrade the benefit to a lesser amount in favor of another dental procedure.

In other words, if you have been recommended to do white fillings, your insurance may downgrade that service to silver (amalgam) fillings (basically stating that they do not cover white fillings).

As an example: if a white filling is covered at 80%, after the downgrade that same white filling will only actually be covered at 55% – this is why at times, you are receiving a bill from your dental office after insurance payment, and after you have paid your initial copayment.

Typically downgrades will happen with white fillings on molar teeth (teeth in the back of the mouth), some crowns, onlays, implants, and at times even some extractions.

Fortunately for you, we know the little tricks of the insurance company, and we usually know what they do and don’t cover. But it does happen occasionally where we have not caught on to all of them – there are simply too many insurance policies out there but we do our best to serve you.

Q: Do you file my insurance for me?

A: Yes – We want you to focus on your health, without the headache that comes with dealing with insurance companies and representatives. We offer complimentary benefit checks so you know prior to treatment how much your insurance company will cover for your needed dental procedure (again this will be an estimate). We will then file your insurance for you, meaning that we fill out the dental form, send them to your insurance, track it for you and receive payment directly so your cost out of pocket is lessened.

We will track insurance claim for 60 days, after which we may decide to transfer the balance to you (this happens very rarely).

Q: Can I only do what my insurance covers?

A: Well that is up to you. We do not dictate our services based on insurance reimbursements. We will give you options for treatment, and it is up to you to accept some of it, all of it, or none of it.

Let’s take the example that a patient has been diagnosed with liver cancer. His insurance decides to only cover a procedure that does not provide any long term benefits to his or her disease. What would you do? Would you go ahead do the right treatment, or will you play with your life and do what the insurance tells you to do?

The majority of the time in which patients are very persistent on only doing treatments that are covered by their insurance, do so because of concerned financial issues. We can help alleviate those concerns with our customized financial menu and payment plan programs.

 

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