Due to much confusion surrounding Dental Insurance, we would like to help our patients understand their options. Our office accepts coverage from all insurance companies (i.e. Aetna, Delta, CompDent, MetLife, etc.); however, we do not accept all of the different types of coverage that these companies provide. The following is a brief overview of the different types of dental coverage or policies that the insurance companies offer.
Note: Almost all insurance policies have both a deductible and an annual maximum associated with them. The deductible is typically in the range of $25-100 and is not usually applied towards recall hygiene visits. The annual maximum is typically between $1,000-$2,000 and does include recall hygiene visits. This total yearly maximum has changed very little over the last 40 years. This is both good news and bad news, since this has kept Dental Insurance affordable as compared with Medical Insurance-- but it also means that it does not cover as much today as it did year's ago.
1. DMO / HMO Coverage: This is a managed-care insurance plan that requires the patient to visit a dentist who has signed a contract with the carrier for this type of coverage. Although this coverage is often the most affordable for your employer to purchase, it forces the patient to choose from a very small list of dentists. The list of dentists is short because the compensation for the dental office is so poor that it often does not cover expenses for optimal dental treatment. Our office does NOT accept this type of insurance.
2. PPO (Preferred Provider) Coverage: This is currently the most common of the insurance policies. It is important to note that there are two types of PPO’s. The first allows you to “go outside the network” and therefore see any dentist you wish; and the other does not allow you to go outside the network. We are not included in any PPO plan directly, so if your coverage does not allow you to “go outside the network” then we cannot accept your insurance. However, much more commonly, PPO’s will allow their clients to see whomever they choose (go outside the network). 70% of our patients have chosen to go outside their network. Note that when you do go outside the network, the insurance company states that you will have to pay more than if you stay in the network. Our experience has shown that these patients often pay the same amount for recall hygiene visits, and just 5-10% more for restorative visits when compared to patients who stay within their network.
3. Fee for Service Coverage: This is the traditional type of insurance policy that allows their clients to see any dental office they wish and pays a specific percentage of dental work. Unfortunately, this type of insurance is not always offered to employees, or often is the most expensive of the employee’s choices.
It is also important to note that all insurance policies that we accept pay a percentage of what they deem UCR, or usual, customary, and reasonable. Unfortunately, the insurance company’s definition of UCR does not always correspond to the existing average procedure fees for the City of Chicago. The following is just an example of what you can expect from your PPO or Fee for Service Coverage (in addition to the deductible- if restorative work is needed):
80-100% of your recall hygiene and x-ray procedures
60-80% of your restorative work (fillings, extractions, root canals)
40-50% of anything that needs to be sent to a dental lab (crowns, bridges, invisalign, dentures, veneers)
If you have any questions about your specific insurance coverage, please contact your insurance company.