{"id":281,"date":"2020-08-14T23:35:23","date_gmt":"2020-08-14T23:35:23","guid":{"rendered":"http:\/\/www.ebsurance.com\/?page_id=281"},"modified":"2020-08-15T00:13:44","modified_gmt":"2020-08-15T00:13:44","slug":"beginners-guide-to-dental-insurance","status":"publish","type":"page","link":"https:\/\/www.ebsurance.com\/?page_id=281","title":{"rendered":"Beginners Guide To Dental Insurance"},"content":{"rendered":"\t\t
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Are you new to dental insurance? Is you company thinking of adding dental benefit for the first time? At EBsurance, we\u2019re convinced that dental care doesn\u2019t have to be complicated or confusing, and we\u2019re here to make things clear and easy to understand \u2014 transparency for the information generation!<\/p>

So let’s get started!<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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Deductible<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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Dental plans typically include a deductible, most likely in the range of $25 to $50. A deductible is the amount that a member is required to pay before insurance benefits kick in. For example, if an individual deductible is $50, that member is required to pay for the first $50 of dental care before taking advantage of insurance. Deductibles for family plans are often limited to a family deductible. This means that if a family plan included a family deductible of $150, coverage would begin once the $150 deductible was met, even if the individual deductibles had not yet been met. In most plans, but not all, deductibles are waived for Diagnostic & Preventive services (see below). Why? Well, insurance companies want members to go to the dentist and get checked out to prevent major issues. Makes sense, right?<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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Plan Maximum<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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Additionally, plans will include a maximum payment, usually just called a maximum. The maximum is the highest dollar amount that a dental plan will cover in a given amount of time for an individual member. For Example, with an annual maximum of $1500, the dental plan will cover up to $1500 of dental services per person each year. If the plan includes orthodontics coverage (read: braces), there will typically be two maximums: one for ortho and one for everything else. Ortho usually comes with a lifetime maximum, while the regular maximum is typically annual.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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Service classes<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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The next important concept you\u2019ll want to understand is dental insurance service classes and how they differ from one another. The term “service classes” refers to the four broad categories of dental care, which are usually covered at different levels by insurance. These categories are:<\/p>

  • Diagnostic & preventative<\/strong><\/h5><\/li>
  • Basic services<\/strong><\/h5><\/li>
  • Major services<\/strong><\/h5><\/li>
  • Orthodontics<\/strong><\/h5><\/li><\/ul>

    \u00a0<\/p>

    Here\u2019s a simple chart to give an overview of the classes:\u00a0<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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    Preventive<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t
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    Basic<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t
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    Major<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t
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    Ortho<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t
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    Typical\u00a0 services Included<\/h3>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t
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    • Cleaning<\/li>
    • Exams<\/li>
    • Basic x-rays<\/li>
    • Fluoride<\/li>
    • Sealants<\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t
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      • Filings<\/li>
      • Extractions<\/li>
      • Root Canals<\/li>
      • Periodontal Services<\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t
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        • Implants<\/li>
        • Dentures<\/li>
        • Advanced oral surgery<\/li>
        • Crowns<\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t
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          • Braces<\/li><\/ul>

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            Typical coverage level<\/h3>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t
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            Plans may differer depanding of carrier and individual plan design<\/h6>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t
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            Diagnostic & Preventative:<\/strong>\u00a0For many people, the majority of visits to the dentist will fall under the category of diagnostic and preventative. Diagnostic and preventative covers many of the services a person receives during a routine visit to the dentist. Exams and cleanings are almost always included, and basic X-rays usually fall into this category as well. In many plans, sealants and fluoride treatment for children under age 14 are also considered diagnostic and preventative. If most of your visits to the dentist involve some combination of these services, you\u2019re in luck. Diagnostic and preventative is typically covered at 100% and often does not require the deductible to be met (but read the fine print!).<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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            Basic Services:<\/strong>\u00a0If you\u2019ve ever seen a dentist for anything other than a routine cleaning and checkup, chances are you\u2019ve received some form of basic service. Examples include fillings, basic gum disease treatment, and extractions; root canals are sometimes included under basic services. If you anticipate needing coverage for basic services, we have good news! Basic services are usually covered at 80% or even 90% with Beam, meaning a member could pay as little as 10% of the cost.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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            Major services:<\/strong>\u00a0This service level covers more complicated procedures, such as complex oral surgeries, dentures, implants, and crowns. Coverage for major services is typically more limited, but if major services are a priority, you can find a dental plan with coverage at up to 60%.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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            Orthodontics:<\/strong>\u00a0If you had braces as a teenager or are the parent of a teen with braces, this category is probably (too) familiar to you. Ortho refers to braces and associated treatments and, when it is included, is typically covered at 50%. The caveat here is that ortho often includes an age limit of 19, meaning that people older than that are not eligible for orthodontic coverage.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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            Network<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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            A network is an organization made up of a group of medical providers \u2014 in this case, dentists. A dental benefits carrier uses a network to give clients easy access to a large number of dentists that will accept their insurance. In turn, dentists in the network gain access to a wider range of potential patients. Additionally, the network determines the fee schedule that the dentist can accept from an insurance company, which frees both the dentist and the insurance company from the administrative work of determining fee schedules for individual procedures.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t

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            Out-of-Network Coverage<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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            What happens if you visit a dentist that\u2019s out-of-network on your insurance plan?<\/h4>

            \u00a0If you receive care from a dentist who\u2019s considered out-of-network, there\u2019s a chance that your insurance will cover a lower percentage of the cost than it would for an in-network dentist. Out-of-pocket costs will depend on whether the plan has a MAC (Maximum Allowable Cost) or UCR (Usual Customary Reasonable) reimbursement.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t

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            MAC<\/strong><\/h2>

            Stands for:<\/strong>\u00a0Maximum Allowable Charge<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t

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            The maximum amount dental carrier pays for a covered service from a provider, whether they\u2019re in-network or out-of-network. What\u2019s the difference, then? It comes down to your out-of-pocket cost. For instance, an in-network dentist may charge more for a procedure than your plan\u2019s MAC fee. Because they\u2019re in-network, though, they\u2019ve agreed to accept the MAC fee. The difference between the provider\u2019s charge and the MAC fee would be written off \u2014 you would not owe this difference. Dental carrier would then cover a percentage of the MAC fee, and you would owe any outstanding balance (coinsurance), assuming your deductible has been met. An out-of-network dentist, however, isn\u2019t contractually obligated to accept the MAC fee. That means you\u2019re responsible for coinsurance\u00a0and<\/i>\u00a0any difference between the provider\u2019s charge and the MAC fee.<\/p>

            Example*:\u00a0<\/strong>This is getting a little complicated, so let\u2019s use an example. Say you need a tooth extraction, and your particular dental plan covers 80% of the cost for the procedure. The MAC fee for a tooth extraction is $100 in your area, and your dentist \u2014 who is in-network \u2014 charges $125. Dental carrier would cover 80% of the MAC fee, which comes out to $80. You would owe $20, and the provider would write off the remaining $25 because they\u2019ve agreed to accept the MAC fees as part of the dental network.<\/p>

            Now, let\u2019s pretend your provider is out-of-network. In this scenario, the provider still charges $125 for the extraction and dental carrier would still cover 80% of the MAC fee ($80). Because the provider is out-of-network, they aren\u2019t obligated to accept the MAC fee, which means they\u2019re still owed $125 in total. Assuming your deductible has already been met, you would pay the remaining $45 owed.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t

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            UCR<\/strong><\/h2>

            Stands for:<\/strong>\u00a0Usual, Customary, and Reasonable<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t

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            The fee for a specific procedure based on what providers in your geographic area charge for it on average. The UCR value is indicated as a percentile and is calculated by a third party based on claims for that procedure in your area (defined by the first three digits in your provider’s zip code). Let’s use a standard dental carrier plan to elaborate on this. The 90th UCR is typical for many of our plans. This means the UCR value for a given procedure will be set so that 90% of providers in your area charge that amount or less. This amount is the maximum dental carrier will pay for a covered service from an out-of-network provider.<\/p>

            Example:<\/strong>\u00a0UCR gets a bit complicated, so let\u2019s go back to the tooth extraction example. To keep things simple, we’ll say your plan still covers the procedure at 80%. Instead of MAC, your plan uses the 90th UCR, meaning 90% of the dentists in your zip code would charge that amount or less for the procedure. We\u2019ll say that charge is $110 in this case. Dental carrier would cover 80% of that $110, which amounts to $88. If your dentist charged $125, you would pay the remaining $37 if your deductible has already been met.<\/p>

            Now, let\u2019s say the dentist charges $100 for a tooth extraction, which is\u00a0less<\/i>\u00a0than the $110 UCR fee. Since the office fee is less than the UCR fee, we would cover a portion of the\u00a0office fee<\/i>. We\u2019d cover 80% of that $100 cost ($80), and you\u2019d owe the remaining $20.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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            Waiting Period<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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            Many dental plans include waiting periods of some kind, but they can vary in terms of length and services they affect. Basically, a waiting period is a given length of time that a member needs to be enrolled before they can take advantage of a certain part of their dental plan.<\/p>

            For example, let\u2019s say you enroll in a dental plan that has no waiting periods on diagnostic and preventative, a three-month waiting period on basic services, and a six-month waiting period on major services. Let\u2019s say your effective date is January 1st. You could go to the dentist for diagnostic and preventative care and take advantage of the plan\u2019s coverage on New Year\u2019s Day . However, if you need care for basic services, you won\u2019t be able to take advantage of the plan until April 1st, three months after the effective date. For any major services, this would increase to six months, or July 1st.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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            Age Limits<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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            The bad news is that some services are only available to people under a certain age. The good news is that the majority of services don\u2019t have age limits at all. Actually, there are only a few places where age limits typically apply.<\/p>

            The first is orthodontics. Orthodontics usually have an age limit of 19 \u2014 this means if you\u2019re over 19 and need orthodontic services, you can still receive treatment, but the costs won\u2019t be covered by your insurance plan.<\/p>

            The only other services that commonly have an age limit are fluoride treatment and sealants, which are typically covered until age 14.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"

            Are you new to dental insurance? Is you company thinking of adding dental benefit for the first time? At EBsurance, we\u2019re convinced that dental care doesn\u2019t have to be complicated or confusing, and we\u2019re here to make things clear and easy to understand \u2014 transparency for the information generation! So let’s get started! Deductible Dental […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-281","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.ebsurance.com\/index.php?rest_route=\/wp\/v2\/pages\/281","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.ebsurance.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.ebsurance.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.ebsurance.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.ebsurance.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=281"}],"version-history":[{"count":4,"href":"https:\/\/www.ebsurance.com\/index.php?rest_route=\/wp\/v2\/pages\/281\/revisions"}],"predecessor-version":[{"id":293,"href":"https:\/\/www.ebsurance.com\/index.php?rest_route=\/wp\/v2\/pages\/281\/revisions\/293"}],"wp:attachment":[{"href":"https:\/\/www.ebsurance.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=281"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}