Why you should know all the ins and outs of your dental insurance plan before you ever lean back in the chair and open wide

Do you want to know what your dentist’s pet peeve probably is? (Okay – aside from complete strangers at a party asking them to “just take a quick look at this tooth and tell me what you think.”)

It’s patients who have no clue what’s covered by their dental plan, what’s covered up to a certain limit, and what’s not covered at all. Some patients can even make it into the chair not knowing their options and unable to decide on what to do.

Most of this is fairly simple and straightforward, but it’s still up to you to make sure that you – and your dependents – get the care that’s required and that you’re entitled to under the plan. That’s not always the same as getting “all the care that’s available under the plan” and it’s also not necessarily the same as “getting only the care that’s covered.”

Start by consulting your dentist on what treatment or care is required. For anything other than basic care, your dentist should be able to give you a written proposed-treatment plan to take home and think over. (And remember that getting a second opinion is always an option when complex or long-term treatment plans are proposed for you or your dependents.)

A little planning at this stage will make sure you achieve the best possible outcome in terms of care received and coverage by the plan.

There are basically three variables to consider on the treatment side.

• Most plans provide coverage for basic care which, as the term suggests, includes most or all of the routine things you may need like checkups, cleaning, cavity repair and so on.
• Some plans may include a level of coverage for restorative (or major restorative) care that deals with things like caps, root canals, implants and other such treatments.
• And, finally, some plans may also provide coverage for certain orthodontic procedures, which consists of often major work to correct naturally occurring problems like overbite, or a crooked smile or misaligned teeth.

Then there are the variables that apply to your particular dental insurance plan. You should certainly talk to your plan administrator at work, read the brochure, and go online to check out the insurance carrier’s details of your plan, your eligibility and your claims history. You can also call the insurance company toll-free number to clear up any details that might still be hazy. Finally, be sure to talk to the billing staff at the dentist’s front desk to make sure you are all on the same page.

Here are some of the questions you should ask.

• Does your plan have a deductible? And, if so, how much is it, and does it apply to each bill you pay, or to each treatment? (This can make a difference on treatments that require more than one visit to complete).
• Is there a co-pay in effect for all or any treatments? Does your plan, for example, pay 80% of the cost, and you pay 20%?
• Is there a limit to treatment in a given time period, and should you plan the timing of visits accordingly? (For example, a maximum amount covered within any calendar year, or any given time period from the anniversary of your enrolment in the plan.)
• On restorative care (fixing lost, broken or decayed teeth), does it matter if the loss or damage occurred before or after the plan came into effect?
• For your proposed treatment plan, are some options covered while others are not?
• Is accidental damage (a fall from a bicycle, or a hockey injury, for example) specifically covered?
• Is there a “lifetime maximum” amount covered for any kind of treatment? (This usually applies to orthodontic care – a plan may have, for example, a $2500 lifetime maximum per plan member.)
• What is not covered at all (that you or your dependents might need)?

Finally, your dental office can also ask for estimates from the insurance provider to make absolutely sure of what’s covered in any possible “grey areas” before you commit to the treatment plan.

The bottom line is that it’s always best to be an informed consumer, to make sure you know exactly where you stand, and to plan your dental care with all the facts in your hands.

Your dentist will respect you for being well informed – and certainly not be peeved.