Hart Dental

Healthy Smiles for Families


Understanding Your Insurance and Making it Work for You!

Posted by Hart Dental of Utah on December 5, 2012 at 1:00 PM

Insurance plans can be confusing to say the least! With unfamiliar terminology and thousands of different group plans, I am here to tell you the basics of your insurance to help you understand how to make it work for you. Just like a snowflake, no two group plans are exactly alike and are constantly changing. We do our best to obtain as much information as possible, so that we can give you an accurate estimate of how much your treatment will cost. It is always a good idea to be familiar with your own plan and to remember that whatever your insurance does not pay, you will be responsible for.



Group plans are employer based plans, meaning your employer forms a group and decides what benefits to offer to the employees within that group. Each insurance company has thousands of different group plans. There are just under 1,000 dental codes assigned for each procedure. Your group determines what percentage of that fee they will pay towards services, with the remainder being your co-pay/portion. Believe it or not, we as a contracted preferred provider do not decide what your portion will be for services, your insurance does! So if you ever wonder why we charge what we do, take that question back to your insurance company and ask how they determine the fees that we charge.



Many people don’t know that if a dentist is a “Preferred Provider” with an insurance company, they have agreed to write off the difference between his or her regular fees and the insurance’s fees. This gives you significant savings right off the bat as your insurances fees are generally lower. If you see a dentist that is not a preferred provider with your insurance and is considered “out of network”, your out of pocket costs are higher because that dentist will charge “usual and customary fees”, which is a fancy way of saying what their regular fees are.


Have you ever gone in to the dentist for a toothache, only to find that your insurance didn’t end up paying on your behalf because of an exclusion, limitation, or frequency of your plan? Have you ever had to pay a bill you thought your insurance would cover? This happens more often than you may think!

Things to watch for:

Be aware of when your plan renews. It can be any time of year. If it is a “calendar year” renewal, then the plan begins January 1st and ends December 31st.

Know what your maximum is. Insurance will pay out a certain amount every plan year on your behalf, and once they have reached that amount, they will no longer pay towards services. Each person in your family will have their own individual maximum. These maximums are not transferrable between members of the family. Maximums renew when the plan renews.

Know what your deductible is and if you have met it. Deductibles are what you have to pay out of pocket before your insurance company will start paying on your behalf and are typically around $50-$100 per individual. They are mostly waived for preventive care such as cleanings. Individual deductibles apply to each person in your family. Family deductibles apply to the whole family. For example, if every member of your family has a $50 deductible, but your family deductible is $150, then only 3 people in your family have to meet that deductible and it won’t apply to anyone else for the plan year.

No matter what provider you see, your plan does not renew with that provider. It follows you everywhere you go! So if you had treatment done at one dentist and decided to switch to another, or you have seen a specialist, the amount you have used applies towards your maximum! This also applies to cleanings; you still have to wait 6 months for another cleaning even if it’s a different dentist. Some plans allow cleanings 2 times a plan year and they do not have to be 6 months apart. We will do free 2nd opinions if you have recently visited another dentist which includes x-rays and an exam.

Know your frequencies and limitations! This is the most important of all, because your insurance does not always tell us about these! Every procedure has a frequency on how long in between you will have to wait until they will consider payment again. Exams are a good example of this. Sometimes your emergency exam shares a frequency with your cleaning exam that is done twice a year, and you can only have two exams of any kind done per plan year, so you will end up paying the full amount of the third exam done.

“Downgrades”/“Alternative Benefits” are when your dentist submits the correct coding for a procedure, and your insurance company changes it to a different and less costly code that will end up costing them less to pay out on. For example, most insurance companies only pay out the price of an amalgam filling, instead of a white composite filling, which cost is higher due to the extra time, skill, and material required. At this point, you are paying your portion of an amalgam filling, plus the price difference between the amalgam and composite filling. The same thing often happens with crowns.

Benefits can change at any time, even if you have been on the same group plan for years! Frequent revisions are made to plans that could greatly affect your out of pocket portion that you had expected to pay. If this happens, alert us when you come in, so we can adjust your treatment estimates.


My best advice of how to look at your dental insurance plan is to view it as more of a “cost share” than an “insurance plan”, with a limit on how much benefit they will pay per plan year. Most of us are familiar with how medical insurance works and are used to going to the doctor and paying one simple co-pay. Dental insurance is different, in that every procedure is given a code, and that code has a shared cost between you and your insurance company. They can pay between 5%-100% of any given code, which can result in an out of pocket cost for the patient. The amount they pay out each year is set, and is much lower than medical plans, usually $1000-$2000 per individual.


Take advantage of the benefits given to you by your insurance company! You and your employer are most likely paying a monthly premium to have those benefits, so why not use them?

Schedule your routine 6 month check-up and cleaning! Most insurance plans pay 100% of preventive treatment for things such as cleanings and x-rays twice a year, with the patient paying 0% out of pocket. So make sure you are scheduling cleanings twice a year! Some plans require minimal co-pays for cleanings, so it’s best to be familiar with your plan.

Split large amounts of treatment up between the end and beginning of a plan year. Insurance can renew any time of year based on your particular group plan. If you plan it just right, you can use your entire maximum and then continue treatment into the next plan year, and your insurance will end up covering more simply because of timing. Many people choose to do this with dental implants or large treatment plans.

Replace old broken down silver amalgam fillings. Fillings are not expected to last a lifetime. Most insurance companies will pay to replace a filling every two years! Decay can form under and around existing fillings, especially ones that are cracked. Some large amalgam fillings will result in a tooth breaking and then needing a crown because too much tooth structure is then missing for a filling to be viable. So take care of it early on and save money in the long run!

Don’t wait to have a filling done, it will only get bigger! It is far less out of pocket to have a filling than it is to have a root canal or crown.

Fluoride can be beneficial at any age and helps prevent cavities and ease sensitivity. See if your insurance will pay for fluoride for an adult at your 6 month check up.

Replace missing teeth! There are several different choices to replace missing teeth for every lifestyle and budget. Some insurance plans have a “missing tooth clause”, which means if the tooth was already gone before you enrolled, they will not pay to replace it, so check your plan by calling the number on the back of your card.


As a courtesy, we will file insurance claims for you. We follow up on claims sometimes several times before they are processed and have to submit additional information in some cases such as x-rays, charting, and narratives. It can take insurances 2 months or longer to process a claim. A lot of time is spent on claims and coding in our office to make sure they are processed in a timely and correct manner. But we cannot influence insurance companies in their processing times and procedures, so we too are at their mercy! They let us know that they do not guarantee any benefit information given to us over the phone, with payment being determined when they process the claim after the procedure is done.


We strive to make our estimates as accurate as possible, but frequent changes can occur to any plan. We deal with hundreds of different group plans among thousands of patients and changes may not be updated every time you are seen. If you are aware of any changes to your plan, inform us as soon as possible. We always suggest that patients familiarize themselves with their plan, because ultimately you are responsible for anything the insurance company does not cover.

In conclusion, your insurance company does not always have your best interest for treatment in mind. We always give you the recommended treatment options regardless of what your insurance company will pay towards them as we care about your oral health and overall well being. It is then up to you to decide which option to choose. Many people allow their insurance plan to steer the choices they make in their oral health, when it is not always in their own best interest to do so. We offer convenient financing to make it easier for patients to choose which treatment is best for them. We are happy to discuss what we know about your plan and what your treatment options are at any time, so please feel free to give us a call or stop by!

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