When you arrive for your appointment, one of the first things we’ll ask you is, “Do you have dental insurance?” Like any insurance, dental insurance can provide valuable peace of mind and can help cover basic needs. However, once you receive your treatment plan, you may have questions about exactly what your insurance covers. We’re here to help!
“I thought I get two free dental cleanings per year?”
In most cases, you do… kind of. Every year you get a “yearly maximum.” Depending on your plan, it could be anywhere from $0-$2,000 or possibly even more. Generally, 80-100% of the cost of your cleanings are paid twice during your benefit period, which is typically January through December.
If your plan covers 100%, then yes, your cleanings will be free. However, if you’ve used your entire budget for the benefit period, then you will be paying for your cleaning out of pocket.
It’s important to remember that these benefits don’t roll over to the new year. If you’ve been putting off caring for any necessary dental work, it’s a good idea to complete it as soon as possible so you can maximize your benefits before you lose them!
“What is a yearly deductible?”
Most dental insurance will have a yearly deductible. During a benefit period, you will personally need to satisfy this portion before your insurance picks up the cost of your dental treatment.
“What is a PPO?”
A PPO, or Preferred Provider Network, allows you to visit any in-network provider/dentist. No matter which provider you choose, services with an in-network provider will be covered at a higher benefit level than services with an out-of-network provider. So a cleaning that may be covered at 100% with an in-network provider may only be 80% covered with an out-of-network provider.
We are a preferred provider for several insurance options; prior to your appointment, check with your specific plan to see if we’re preferred to really maximize your benefits.
“I thought I paid my portion on the day of my appointment. Why am I getting another bill?”
Dental insurance is designed to help with some of your expenses, but may not cover every need. Most insurance plans have limitations. Here are some common scenarios:
- A fluoride treatment may be covered at 80-100%, but will occasionally have an age limitation. Your child may have had fluoride treatment covered in the past, but if there’s an age limit of 18, fluoride will no longer be covered once he or she reaches 18.
- A crown may be covered at 50%, but occasionally, a treatment on a single tooth will have a time limitation. Here’s an example: Let’s say you had a crown placed three years ago and it needs to be replaced. If your insurance only covers the same treatment on a single tooth once every five years, you’d be responsible for 100% of the cost of the new crown.
- If you saw Dr. Nosti and a specialist around the same time, your insurance may pay the specialist first, which could max out your benefits. If that happened, your office visit with us wouldn’t be covered by your insurance, and you’d be responsible for the cost of the visit.
“Dr. Nosti told me I have to get my teeth cleaned four times a year. Will my insurance pay for that?”
There are different types of cleanings:
- Prophylaxis cleaning (or a prophy) is a regular cleaning and is appropriate for a patient with a healthy mouth that only needs to be cleaned and checked every six months.
- Scaling and root planing (or a deep cleaning) is required for a patient with unhealthy, bleeding gums. An extensive cleaning is done below the gumline (where your floss and toothbrush can’t reach) and usually anesthetic has to be used to help the patient feel comfortable during the cleaning. Depending on the case, this may need to be done every three to five years. Some insurance will cover this. However, regular cleanings and good flossing habits can help you prevent the need for this procedure.
- Periodontal maintenance (or perio maintenance) is completed after a deep cleaning to help maintain the health of the mouth and to prevent additional problems. This type of cleaning is recommended every three to four months.
For the most part, your dental insurance will pay for all or part of two prophylaxis cleanings a year. Some plans cover periodontal maintenance. If you need this type of treatment, we provide your insurance company with additional information to ensure you receive coverage.
“What if I don’t have dental insurance?”
We know navigating dental insurance options can be difficult, which is why we endeavor to explain all costs involved with your treatment plan upfront. We want you to feel comfortable with every aspect of your experience at our New York dental practice!
Remember, insurance benefits don’t roll over from year to year. Use your benefits, don’t lose them! Call our office at (212) 619-4070 to book an appointment today!