Let’s Talk About Dental Insurance Maximums

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Dental insurance is such a fascinating topic…..wouldn’t you agree?  Ok, I am saying that in jest of course. It’s boring as heck, but it unfortunately it is something that is very important and is often overlooked and taken for granted by many people.

Many patients are not fully aware of their dental benefits. We find that patients often think that they have coverage for something, only to find that when the time comes for dental treatment they in fact do not have the coverage they thought they had.  It is my hope in today’s blog to help explain a specific area of your insurance; to help you “get ahead of the curve” so that you have a better handle on what your own unique dental plan covers.

There are many aspect to dental insurance but I would like speak specifically about an area of dental insurance that is often the topic of discussion at the end of the calendar year: dental insurance maximums.

Dollar Maximums

Most dental insurance plans (but not all) have maximum dollar amounts that they will pay out for dental treatment. This maximum dollar amount is usually paid out over a specific period of time. The insurance plan may have no maximums at all, one maximum, or it may even have a combination of maximums on different levels of coverage within the same plan.

No maximum or unlimited maximums mean that there is an unlimited dollar maximum placed on what is to be paid out for any given service. Keep in mind however that this does not include the maximum amount for the fee schedule, plan limitations, co-payments, deductibles etc.

Calendar year maximums are pretty much what they read as….calendar. They run from January 1st to December 31st of any given year. At the start of the next year you will begin again with the full amount of benefit under your plan.

Consecutive maximums are usually a policy year and work on a rolling basis. An example of a consecutive year maximum would be if your employer purchased a plan, or if you started work with your employer on August 1st. The consecutive maximum would then run from August 1st through to July 31st the following year. Consecutive maximums can be a bit trickier to keep track of than a straight calendar year as you need to keep track of the date your consecutive year starts.

Below is an example of the common types of dollar maximums that you may see under a dental plan:

“DENTAL PLAN FOR COMPANY BEE”

Level 1 – Basic treatment including check-ups, cleanings, fillings

Paid at 100% of current fee schedule

No maximum

_____

Level  2 – Crowns, dentures, bridges

Paid at 50% of current fee schedule

$500.00 maximum per calendar year

_____

Level 3 – Orthodontics – dependent children to age 17

Paid at 50%

$1,200.00 life time maximum

Scaling Maximums

Let’s talk about dental scaling.

Some services under a dental plan are limited to a frequency.  Units of scaling are a popular service that is often limited in frequency under dental plans.  If there is a frequency limitation on scaling under your plan it is usually based on a calendar or a consecutive month period of time.

Calendar frequency and consecutive frequency for scaling will work the way that I have outlined above for dollar maximums.

In addition to the frequency of the scaling, dental plans will also have a plan limitation on the quantity of scaling units. They may have unlimited units of scaling or a limitation on the units of scaling.

The limited units of scaling can be any number such as 6 units, 8 units, 12 units etc. Please keep in mind the number of units that your plan limits scaling to is not an indication of the necessity of care that you require. We can not emphasis this enough.  It is only an indication of the level of coverage that your employer wanted to purchase from the insurance company.

When an insurance company declines to cover dental care, many people are under the false impression that it means that treatment is not necessary. Nothing could be farther from the truth! The fact is, insurance companies offer as many different types and levels of insurance plans and coverage as there are vehicles on the road. When an insurance company declines a dental procedure it is simply a matter of what is or is not covered under the plan that has been purchased. If this is a group plan it is most likely purchased by your employer.

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Your Insurance Benefit Booklet

Everyone with dental insurance benefits should have access to information outlining their dental insurance benefits. If you do not have this information, or if the information that you have is more than a year old, we recommend getting in touch with your employee benefits co-ordinator to find out how to obtain the most recent version of your benefits booklet.

With recent changes to the privacy act we as a dental office are often prohibited from obtaining information about your dental benefits from your dental insurance company. Again, with so very many types of insurance plans on the market it is impossible for dental offices to keep track of the various nuances of insurance plans. We do however, want to assist our patients in interpreting their insurance benefits and assist them in determining how they can best utilize their dental benefits to obtain their maximum dental oral health.

Please bring in your most current benefit booklet to the office and we will be happy to make notes and keep a copy of your most current benefit booklet in your file. Should you have any questions with regards to treatment and how it relates to your dental benefits we will have a benefit booklet on hand in your file to reference.

DO check on a regular basis with your employer to make sure that you have the most current version of your benefit booklet. Often benefits will change during contract negotiations or at insurance renewal.

Yours for better dental health,

Gail Allen

Patient and Marketing Coordinator

Oakville Dental

Gail has over 25 years in combine group dental insurance and dental administrative expertise. She has obtain LOMA Certification with the Insurance Council of Canada.

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