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How to Make Sense of Dental Insurance

Posted on 2/22/2021 by Joseph Kabaklian DDS
Doctor speaking with patient and using a laptopAs your Newport Beach dentist, I often get a lot of questions from patients if it's worth it to buy dental insurance or what their EOBs and pre-auths mean. I also get asked to give them their exact copayment for a procedure. In this post I will talk about all the topics if someone should get dental insurance or not.

First let's address the two big types of private insurance. There are HMOs and PPOs. A PPO is also referred to as a fee for service insurance plans. This means that whatever procedure or service is done, (such as an exam, x-rays, fillings or whatever else) it will be billed to the insurance hoping the insurance will pay the dentist for that procedure. There are hundreds of different kinds of PPO plans and HMO plans so the premium, deductible, and copayments can vary with each one. Also there are a lot of different services that are covered by the insurance or not. Some insurance plans will cover white fillings but some won't and will pay less money for a silver filling. Some insurances will pay for implants and some won't. So now that we know a little more about PPO, let's briefly discuss HMO plans because this is an insurance plan that we do not accept at Enamel General and Cosmetic Dentistry. HMO is a capitation plan. This basically means that the HMO will give hundreds of patients to the dentist and pay him/her a small amount every year for the patient to belong to that practice. Whether the dentist does work or not they still get paid a small amount for the patient to belong to the practice. Lots of things are covered under an HMO plan but other services have a very high co-payment. So even though the premium (the cost of the insurance plan monthly) is very low, usually the patient's co-payments are very high. Let's simplify for this post, PPOs are lot more simple where you bill and get paid on the work you do while HMOs have large co-payments and “upsells.” This is why at Enamel General and Cosmetic Dentistry we accept every PPO insurance.

Let's talk more about PPO plans. With every PPO insurance plan there is a premium. Sometimes your employer pays the premium so you essentially have free dental insurance. Another bill you might receive is your deductible. Usually on PPO insurance plans the deductible is $50 and you have to pay the deductible on fillings, deep cleanings, or more major procedures. This means usually there is no deductible on x-rays exams and cleanings. Another thing to be aware of are co-payments. When you receive a breakdown for dental insurance it says preventative 100% covered for example, then it says restorative minor 80%, restorative major 50%. Exams, cleanings, and x-rays fall into the preventative category, fillings in the restorative minor, and crowns, root canals, and extractions in the restorative major category.

So what does all this mean for you? PPO dental insurance is very different from medical insurance because you have a maximum benefit of usually $1500. This means that the maximum the insurance will pay out in one year is $1500. But, different plans have different maximum benefits so make sure to check when deciding on a plan. So now let's put it all together. We know there is a monthly premium, a deductible, and copayments so if you get a quote from a dentist for all the work you can check if dental insurance is actually worth it. This is what I recommend to all Enamel General and Cosmetic Dentistry patients. I recommend going to the dentist, we charge $50 for an exam and x-rays, and get a full treatment plan to see what's needed. Then we could see if you're actually saving money with dental insurance. Usually once we see what's needed and compare all the out of pocket expenses with dental PPO insurances, patients elect to pay cash. If you ever need any help with crunching the numbers please call our office at 949-991-2499, and we will be happy to help!

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Enamel General and Cosmetic Dentistry is a patient provider in Newport Beach, Costa Mesa, Irvine, Santa Ana, and Huntington Beach, CA. Learn more here!
Enamel General and Cosmetic Dentistry, 20162 SW Birch St, Suite 200, Newport Beach, Ca 92660, 949-991-2499,, 7/9/2024, Key Phrases: dentist,