Dental Insurance. Are Your Covered San Diego?

Dental Insurance...
Like a Hospital Gown, You Only Think You Are Covered…

To an extent, we have become a society of people who think someone else should take care of our problems.  The recent Health Care Bill, the ramifications of which are still unknown to us, was pushed-through/strong-armed/carefully-crafted/media-manipulated (take you choice of adjectives) on the basis everyone should have care, even if we can’t or don’t wish to pay for it.

The “Good Hands People” and their ilk have convinced the public they provide benefits, and they are looking out for us.  This has resulted in the faulty notion that having dental coverage will cover most if not all or your potential dental needs.  This is simply not the case.

To an extent with medical insurance, it is true.  While I personally have a huge deductible, should I need catastrophic care, I will not go bankrupt staying alive.

Dental insurance is a different animal.  It is more like a contract to provide a very limited set of benefits to a very narrow range of dental health needs.  It was never set up to hand dental catastrophes.  Instead of costing money for inexpensive procedures, dental insurance will often cover the cost of care which cost almost nothing:  exams, x-rays and cleanings.  When you really need extensive care in dentistry, unlike most medical, your coverage vanishes.

The dental insurance industry started in the early 1960’s.  The average indemnity plan paid $1000 in benefits per year.  They paid most if not all of the costs for minor care:  exams, x-rays, routine cleanings, fillings.  They always cut to a percentage as the procedures became more costly, however a few things changed of the past 50 years.

The maximum yearly benefit which as $1000 in 1963, adjusted for inflation now provides about $100 worth of comparable benefits.  If they paid 50% of the cost of a crown then (crown fee was about $200 then), you would have benefits 50% of 20 crowns.  Of course the premiums have gone up over 1000%.  There is a reason some dental plans have billions of dollars in reserves.  They are keeping money which should be paying dentists for care they provide.

Now, most plans have a maximum yearly benefit of $1000-1500/year.   With the cost of a crown in 2010 between $1000-2000, 50% coverage and a $1500/year maximum does not help much!

Now what else has happened with dental insurance? 
Well, some plans have developed which have better benefits for the patient is you go to a “Preferred Provider”.  This means the insurance plan prefers that office because the office has agreed to accept less money for procedures.  The bigger plans like Delta got everyone accepting their contracts years ago, then gradually downgraded what they considered “Usual & Customary” which is insurance-speak for “we will pay whatever we feel like and will not tell you who were arrived at the number”.  In essence, they want everyone to be paid the same as the poorest clinician, using the cheapest materials and labs.

Even worse are the restrictions placed by other types of insurance plans. 

In HMO plans you can only go to a plan provider.

The most heinous plans are what are called “Capitation Plans”.  In these plans, the office gets a set amount every month per patient signed up at that office, WHETHER OR NOT TREATMENT IS PROVIDED.  Guess how an office can make the most treating these patients.  Yep.  Don’t see them at all, or do nothing for them if they do.

Additional insurance loopholes to insure profit THEIR profits, is to place additional restrictions.  These restrictions could be yearly maximums, not paying out-of-network doctors the same or at all, limitations on what services are provided (no implant benefits, or adult orthodontics), downgrading filling to silver-mercury fillings (which I have not placed in 15 years) vs. bonded tooth-colored resins, waiting periods of up to a year for “major” (i.e. more expensive) procedures, no benefits for any procedures they deem as potentially cosmetic in nature.

Now, if I come across as being cynical, mea culpa.  If you are an adult having little to no dental needs, or are a small child with decent dietary and hygiene care, dental benefits, if provided as part of you employment packages does help and is a small but nice benefit.

If you expect to find out you are covered for dental reconstruction, implants, TMJ care, adult orthodontics, any type of cosmetics care, please to not expect your plan to provide that level of care.  Your employers, if they provide dental benefits decide who much they can allocate towards this benefit.  They are then presented with plans from a broker to fit the allotted budget. 

Are ways for an employer to circumvent the insurance companies and their inherent overhead and built in profits.  There is a way for a company to self-insurance and provide Direct Reimbursement directly to the dentist who you select for your care. 

Should anyone have questions about their options as an employer, or a plan participant, please call my office.  We would be happy to explain the nuances of any plans you may be considering.

Remember, dental insurance is like a hospital gown, you only think you are covered.