Dental Insurance 110 – The Fun Stuff!

Hi again, happy Tuesday!? If you remember last week – we did a lot of convoluted (aka insurance) math.? I want to dive deeper this week and talk about some nuances of dental plans.? To recap – we went through how important it is to read and understand the fine print in your dental plan – specifically how out of network services are treated and reimbursed because the costs are so different in-network and out-of-network.

Before we go any farther, I want to remind the parents reading this that the Affordable Care Act requires medical plans to offer pediatric dental coverage.? It’s not great, but it works.? Pay special attention to the plan structure, sometimes the child is assigned an HMO dental product.? I point this out, because I hate seeing people spend unnecessarily on coverage, but dental coverage is vital and a strong plan is so important, especially for kids.? I’ve loved my pediatric dentists and they’ve been PPO dentists only.? As a result, I’ve always added my kids to my dental plan at work and not used the pediatric dental benefit at all.

Let’s do deep dive into coverage.?

1 in 4 Americans has some type of gum disease (beyond gingivitis).? Gum disease, also referred to as periodontal disease, has huge health implications!? It’s been shown that people with periodontal disease are more likely to have heart issues later in life.? Considering the complications that may arise from periodontal disease, it’s super important to get treatment to mitigate the effects. Unfortunately, dental insurance isn’t like medical insurance and treating periodontal disease can get expensive.

A typical dental plan covers:

Preventive and diagnostic services at 100%

Basic services at 80%

Major services at 50%

You’ll see this illustrated as 100/80/50.

When reading your plan docs you might see endo/perio in basic. This means that endodontics (think root canals) and periodontics (like deep cleaning) are covered in the basic tier.? This isn’t always the case though and it’s vital that you understand what tier both therapies fall into before you have a situation where you need care.? I’ve seen perio covered as a basic service and endo covered as a major service or both listed as major services.

I also want to bring up orthodontia.? Most of the time orthodontics is just a child benefit, but some plans include adult orthodontics! ?Ortho treatment always has its own limit and coverage is usually limited to 50%.?? Some limits are annual, but most will be once a lifetime.?

Now – something fun!? You all know I’m a proponent of pre-tax plans and being a smart consumer.? Some dental plans have enhanced maximums or rollover features.? Rollovers are the best thing ever.? Think of a rollover account as a special savings account the insurance company is giving you.

If your plan has a rollover feature built in, make sure you make it to your dentist at least 1 time a year!? I’m serious, no claim, no rollover!!

It works like this:

·?????? You go to the dentist at least once a year.

·?????? Spend less than the rollover threshold (this will be determined by your plan, but we’ll use $500 for this example).

·?????? The insurance company gives you a credit of half your threshold to use in the next year. ?And this may be more if you only utilize in-network dentists.

·?????? You can collect the credit and accumulate up to 4x the rollover amount over time.?

What’s that look like?

Year 1:

$1,500 annual maximum

1 claim of less than $500

Rollover awarded: $250

Year 2:

$1,500 annual maximum

$250 rollover credit (total annual maximum $1,750)

2 claims totaling < $500

Rollover awarded: $250

Year 3:

$1,500 annual maximum

$500 rollover credit (total annual maximum $2,000)

2 claims totaling < $500

Rollover awarded: $250

Year 4:

$1,500 annual maximum

$750 rollover credit (total annual maximum $2,250)

Root canal needed; patient has an extra $750 to apply towards the root canal! The rollover amount ensured the member has enough funds to cover their prescribed treatment AND make sure they can continue to get their twice-yearly cleanings.?

Rollovers are tracked for each person in a family, which means everyone can accumulate additional benefits dollars.? Remember – you must have at least 1 claim a year!

One last note on rollover credits – they can’t be used for orthodontia.? (This is where I insert my typical – it’s insurance, there’s a caveat).

One last feature that your plan may have is the Preventive Maximum Waiver.? I normally see this in lieu of a rollover feature.? Preventive max waivers allow you to get your preventive and diagnostic services every year, without reducing your total annual benefit.? This plan structure basically increases your annual maximum by about $500 a year.?

So, what happens if you don’t have any of these features in your plan?? What if you max out?? You can still get care if needed and discounts if you go to an in-network dentist.? In-network providers must charge you the negotiated rates even if you’ve gone over your maximum.?

Don’t forget to utilize your flexible spending account to pay for dental expenses.? Those of you enrolled on an HSA, you can use HSA dollars OR the funds in your limited flexible spending account.? If you are a parent and your child needs braces, fillings or to have their wisdom teeth removed, you can use your FSA funds towards those costs.? Save the taxes and remember, you can reimburse yourself from your FSA account, just like you would from an HSA.?

If you’ve got questions or want to explore anything health and wellness related – let me know in the comments.? Be well, Sirena