by Sarah - Here at The Tooth Doctors, we take pride in assisting our patients and the community in understand all aspects of oral health and maintaining a healthy smile. When it comes to scheduling a dental visit, usually one of the first questions people ask is “is this going to be covered under my insurance plan?” While dental insurance is a valuable component of health benefits, to help offset the cost of treatment, many people don’t realize that insurance plans are not designed to meet individual health needs. As well, due to privacy limitations, the information available to your provider about your plan is extremely limited. Understanding how your plan works and the responsibility of the dental provider can help you make informed choices for your oral health.
Every insurance plan is a little different; some cover certain services, partially include others, and exclude some altogether. There are over 30,000 dental plan contracts in Ontario; these are lengthy, complex documents that define what services are covered and under what circumstances those services are eligible for reimbursement. The employer determines the plan they wish to purchase and enters a contract with a third party that will act as the plan administrator, who is obligated to reimburse patients based upon the terms of the dental plan contract. This means in some instances, necessary treatment may not be covered.
In general, four types of services can be covered by a dental insurance plan: basic, comprehensive basic, major and orthodontic.
Basic; routine maintenance treatments
Comprehensive Basic; beyond the scope of routine but still necessary treatment
Periodontal treatments: deep scaling, bite adjustments
Endodontic treatments: root canals, pulpotomies
Oral surgery: maxillofacial deformities, fractures of the jaw, excision of cysts
Standard denture services: repairs, adjustments or add-ons to existing dentures
Major; extensive treatments
Orthodontic; treatment of irregularities in the teeth and jaw
Appliances: habit, expansion, space maintainers
Before any of these services are covered, your insurance plan may require you to pay a deductible at the beginning of each benefit year. Each of these service categories may have different reimbursement levels and maximum dollar amounts allowed within a benefit year, for example, Basic services are often covered at the highest amount (usually 70-100% up to $1000) as this gives you financial incentive to maintain good oral health and prevent the need for further treatments. Most plans also include limitations and exclusions, as well as clinical review by one of their licensed dental consultants, for example, 1 dentist check up exam and xrays per 9 months, 12 scaling units per year and fluoride for anyone under 18. Keep in mind, a typical adult check-up visit uses 1 dentist exam and xrays, approximately 3 units of scaling and .5 units of polish. So, according to my example, you would be covered for a typical dentist check-up exam every 9 months but additional scaling with a hygienist on 3 other occasions throughout the benefit year.
If your plan only covers a percentage of the treatment cost, you are responsible for the remaining treatment balance.The amount your dentist may charge for services and the amount of money your plan reimburses you might be different as these two prices are not derived in the same way. Your employer, when determining a plan, will consider factors such as company funds available, the nature and extent of use and which version of the Ontario Dental Association Fee Guide is used. The Ontario Dental Association Fee Guide is a reference of suggested fees for dental services that are updated annually. Your dentist will refer to the current issue of the fee guide as suggested prices and consider factors that affect both the practice and their patients.
To plan ahead and inquire about your coverage, you can request that your dental provider submit a pre-treatment estimate. This estimate will include an overview of services covered by your plan and how co-payment, deductibles and dollar maximum limits might affect your share of the cost. Sometimes, additional information may be requested by your plan administrator in order to ensure that the treatment is necessary and covered by your plan. In such cases, the plan administrator will ask you to obtain the information from your dentist. Your dentist will supply that information you request.
Remember, you are a partner in your oral health. All treatment and care decisions should be made by you and your dentist based upon your oral health needs regardless of what your plan covers. Prevention is still the best treatment for everyone; brush and floss daily, limit sugary food and drinks, snack less often, don’t smoke, and please, have a dental exam regularly to maintain a healthy smile.
Ontario Dental Association (2017). Dental Benefits Explained. Retrieved from https://www.youroralhealth.ca/you-your-dentist/dental-benefits-explained91
British Columbia Dental Association. Dentists treat you, not your dental plan. Retrieved from https://www.bcdental.org/WorkArea/DownloadAsset.aspx?id=5520
Prout, Gavin (2018). Understanding Your Dental Insurance Plan and the Types of Services Available. Retrieved from https://www.sbis.ca/understanding-your-dental-insurance-plan-and-