Dental Insurance 101 – A Quick Guide to The Basics

  • By StarBrite Dental
  • 03 Sep, 2015

Understanding dental insurance and how it relates to maintaining your very best oral health can be challenging. There are so many specialized terms and complex nuances that the whole thing can be a nightmare to think about.

Our goal with this article is to explain the basics of dental insurance in plain English. We want to make it easier for you to make informed decisions about your families health and dental care.

First you’ll need to grasp several basic terms in order to understand how insurance benefits work. We’ll define them in simple words and then explain how they affect both you and your trip to the dentist.

Insurance benefits
These are the health care services which are covered under your health insurance plan. Some plans cover more services and some cover less—it depends what sort of insurance you have.

Dental treatment may or may not be covered by insurance. Sometimes insurance covers only a portion of it. Sometimes only certain procedures.

Annual limit
An “annual limit” is a cap on the benefits your insurance company will pay in a given year. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated health care costs for the rest of the year.

“Co-” means “with.” Therefore, a copayment or “copay” is the amount you pay “with” the insurance company. When your health insurance covers a particular service or treatment, they require you to pay a portion of it out of your pocket. This is your copay. The amount you’re required to pay varies based on the type of insurance, your coverage and by the kind of service you receive.

Preferred Provider Organization (PPO)
This is a type of financial arrangement an insurance company makes with medical providers such as dentists, hospitals and doctors, to create a network of “preferred providers.” This insurance company then dictates what services are allowed to be covered by these doctors and how much they’re allowed to charge. Dentists participating in PPOs are often limited in the care they’re able to provide. When they agree to be a “participating provider” with that insurance company, they have to accept a specific payment schedule and limitations on treatment.

“In-network” provider
This refers to doctors or health care facilities that are part of the health plan’s network of providers. This means the insurance company has negotiated with the doctor, agreeing to send them business if the doctor will follow specific rate and treatment requirements.

“Out-of-network” provider
This refers to physicians, hospitals or other health care providers who haven’t created a business relationship with a specific insurance plan. Typically insurance will still reimburse patients for treatment they receive at an “out-of-network” provider. However, they may not reimburse as much as they would for one that is in network.

“Fee-for-service” provider
“Fee-for-service” describes a doctor or health care provider who is paid directly by the patient for treatment. Insurance will still reimburse patients for the treatment they receive, but may not cover as much as they would if the doctor were “in network.” Fee-for-service providers will often even submit the patients insurance claim and help them follow up to get paid. The difference is that the insurance money goes directly to the patient and the patient pays the doctor’s office.

At StarBrite Dental, we’ve chosen the fee-for-service model because we believe it’s the best way to provide excellence to our patients. Insurance companies are far from the site where your dental care is being provided and their decisions are necessarily driven by financial concerns.

We’re motivated exclusively by the highest-quality care and continued good health of our patients. As a result our decisions are only influenced by one thing: what’s best for them.

If this sounds like the kind of excellence you are looking for and you’re new to our office, we offer a Free Dental Consultation. Schedule your appointment for this consultation by calling   (301) 377-2186 . We serve patients from all over the Washington, D.C. area and look forward to helping you with your dental care.


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