A Guide to Understanding Dental Insurance
Understanding and having a dental plan in place can really ease the cost of regular checkups, cleanings, repairs, and extensive dental procedures.
When it comes to maintaining your oral health without any financial coverage, you really do put your money where your mouth is!
Dental Insurance in Alberta
In Alberta, general Oral Health Care is not included in our Canadian Health Act (CHA).
Many Albertans are provided healthcare through their employer or through a government-funded program, such as Senior’s 101, Alberta Works or Child health Benefits.
You can purchase a supplemental dental plan through a number of private health benefit providers. This is particularly useful if you have no existing employer-based health plan, are retired or self-employed.
The key to understanding the difference between your Dental Plan and a Treatment Plan is crucial.
A Dental Plan is an arrangement made between the patient and their insurer. The insurer sets the coverage and frequencies for treatment that is covered under the plan provisions.
A Treatment Plan is a planned treatment made by you and your Dentist. These plans are devised to meet your Oral Health goals but may not always be covered under your insurance provider.
What is Co-Payment?
Co-Payment (also known as co–insurance) is the portion of the bill that is the patient’s responsibility.
Many dental plans have co-payments or in other words a portion of the claimed amount that will not be covered.
Patients may be told that their plan covers 100 % however insurers often have a maximum payable amount that may be lower than the actual dentist’s fee for the services rendered.
How Much Do I Have To Pay?
That will all depend on the plan you choose.
There are many variations so it’s always important to know your plan details.
Some plans set annual deductibles, limit plan spending, cap dollar amounts, and limit the number of visits allowed in a benefit year.
Dental plans often do not cover every dental procedure, however, for the basics including regular check-ups, x-rays, hygiene (cleaning), fillings, root canals and extractions will usually be partially paid out.
Minor Procedures
The ratio for insurance payments in minor procedures is typically 80% -20%.
This means that an insurer is likely to pay about 80% of the treatment costs according to their own fee guide, leaving the 20 % an “out of pocket “expense for the patient.
Major Procedures
For treatment deemed major, such as crowns and bridges the ratio is more likely to be 50% – 50% of the insurer’s fees.
It is important to understand that the majority of dental clinics may be using their own fees for procedures and not the ones set by your insurance company, resulting in a higher co-payment for the patient.
Your Dental Clinic can also provide you with a predetermination of costs.
A predetermination is a request sent to your insurer asking for coverage and estimated reimbursement details.
This gives the patient an idea of what will be covered and what will be “out of pocket”.
However this is just an estimate and may differ when the time of treatment happens, it is a good resource to use when wanting to know what your benefits will help you with.
CAN MY DENTIST WAIVE MY CO-PAYMENT?
No. Any waiving of patient portions is insurance fraud and is against the law.
Your dentist can be heavily fined for this or even lose their license.
When you and your dentist sign the claim form that goes to the insurance company, you are stating which services were provided and how much, in total, was charged.
The insurance company pays its share based upon the assumption that you will do the same.
WHAT IS DIRECT BILLING?
Direct billing occurs when your Dental provider sends their bills straight to the insurance company for payment, rather than having the patient receive the bill and file the claim.
This eliminates the need for the patient to handle the initial interaction with the insurance company.
However, it doesn’t eliminate the need for a patient to pay costs that aren’t covered by his insurance agreement.
YOUR DENTIST’S ROLE
The first advantage a dentist provides is being able to give a forecasted dental treatment proposal.
This way everyone knows what the next step will be and can work together with your insurance company to manage your dental goals.
Ultimately your Dentist treats patients and not dental plans.
QUESTIONS TO ASK YOUR INSURANCE PROVIDER
It is strongly suggested to contact your dental insurer and ask these questions.
This will give you more knowledge when making decisions about your treatment when at your dentist’s office, as well as helping the dental team treatment plan what will work for you.
Unfortunately, the majority of insurers do not allow anyone but the insured themselves to call and request any information on your plan.
- What is my benefit year? – Does it run annually or mid-year? Jan – Dec for example.
- Do I have a deductible?
- What is my maximum dollar amount for my benefit year? Does this include both minor and major procedures or do I have a separate maximum for both?
- What is the percentage covered for my minor procedures?
- What are the percentages covered for my major procedures?
- What are my frequencies for my checkups and cleanings? Can I come every 6, 9 or 12 months?
- How many units of scaling (removing the plaque) do I have to use in my benefit year?
- Do I get fluoride? Is there an age restriction?
- Do I have any Orthodontic coverage?
Please do not hesitate to call our clinic and speak to one of our administrators.
All of our Sierra Dental staff are fluent in insurance and are happy to help.
If we do not know the answers we will find them for you.
We also offer direct billing, predeterminations of treatments, and financial arrangements to all our patients to ensure smooth and easy payment transactions.