Female client consulting with a agent in the office

Everything You Need to Know About Dental Insurance

An interview with our office manager Marco about dental insurance

Dental insurance can be a complicated and confusing topic for everyone involved, but especially you-the patient!  We interviewed our office manager Marco Monteiro to clarify some of the most common problems and misconceptions when it comes to dental insurance.  Marco handles all of our dental insurance at the office, and he is also a licensed Insurance Agent in the state of Florida; so he really knows this topic inside and out! 

Our Jacksonville FL dental office accepts many dental insurance plans and we are happy to verify your benefits for you before your dental appointment. 

Is it necessary to have dental insurance to have dental work done?

No!  Only about half the population has dental insurance, and everyone needs to see a
dentist!  At our office we have the River Oaks Dental Savings Plan, which is a membership plan for patients without traditional dental insurance.  Nearly all of our uninsured patients sign up for this plan because it covers all their preventive care like cleanings, exams, and x-rays at a low yearly rate.  The rate for our savings plan is actually lower than most people pay for their private dental insurance or dental insurance through Medicare.

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Speaking of Medicare- does Medicare cover any dental?

Traditional Medicare does not have any dental benefits.  There are some supplemental plans you can purchase through Medicare.  In our experience most of these are very limited in what they cover and often are not much of a benefit to our patients.  However we do take some of these plans in our office and we are happy to research if your specific plan is one we accept.

What is the difference between an in-network vs out-of-network provider?

For most dental plans, it doesn’t make that big of a difference if you see a dentist who is in-network or out-of-network.  The exception would be if you have Medicaid or an HMO plan that assigns a specific dentist to you and doesn’t allow you to see other dentists.  However, most dental plans available today are PPO plans which allow you to use your dental insurance anywhere.  With medical insurance, seeing an out-of-network provider can be extremely expensive (or even impossible-an out-of-network physician often declines patients who are not in-network with the plans they accept).  Dental, on the other hand, is much more flexible in allowing you to use your benefits with any dentist you choose. 

What plans are you in-network with?

We are in-network with most PPO plans, but we encourage you to call with your insurance information so we can run a complimentary benefit verification for you before your appointment.  We are in-network with plans such as Delta Dental, MetLifeBCBS (Florida Combined Life), UnitedHealthcare, Cigna, and Aetna, just to name a few.  This is not a complete list! 

Which plans are you out-of-network with?

We are out-of-network with UnitedConcordia PPO.  There are also a handful of PPO plans that we are out-of-network with either through Medicare or out of state insurance companies.  It’s best to let us know your information ahead of time so we can check this for you.  Most of the time with PPO plans you can still receive care in our office and have dental insurance benefits available to you!  

Unfortunately some plans cannot be used in our office at all, including active duty TriCare, Medicaid, HMO plans, and some Medicare plans.  This doesn’t mean you can’t receive care in our office- just that you won’t be able to use that dental plan.  But don’t worry, we have lots of affordable options for your dental care including our River Oaks Dental Savings Plan. 

Why doesn’t my insurance cover this!?

Dental insurance companies have lots of exclusions and limitations they put on their benefits to save them (not you!) a lot of money.  For example, most plans have annual limits between $1000-$1500.  This means after paying out $1500 for the year, the insurance company is off the hook for your dental care and you pick up the rest of the tab.  This is basically the exact opposite of health insurance where after reaching an annual maximum, you no longer are expected to pay copays for your care and insurance pays 100%.  This is a real problem for people with dental needs beyond basic care.  $1000 goes quickly- between two hygiene visits and a couple fillings, your annual benefits are used up. 

Insurance companies often have clauses like frequency limitations (for example they might only pay for a full set of x-rays every 5 years, or a new crown every 7 years), and other exclusions like a missing tooth clause (if you were missing the tooth when you started the plan they won’t cover any treatment to replace that tooth).  Other times they may only pay for the least expensive acceptable treatment (for example they may decide to pay for a partial denture instead of an implant or a bridge, leaving the patient with a much higher out of pocket expense than expected.

What’s a pre-determination?

A pre-determination is essentially submitting a proposed treatment to the insurance before treatment has started in order to get a more accurate determination of benefits for that procedure.  However, insurance companies will remind us (in fine print) that a pre-determination is not a guarantee of payment.  They can say they will cover the procedure at a certain amount and then still deny the claim.  The process of submitting a pre-determination can sometimes take months, and often our patient can’t wait months to have that treatment done.  For those reasons we do not routinely submit pre-determinations to insurance unless the patient requests it. 

Insurance sounds like more trouble than it’s worth.  Is it worth it to buy dental insurance?

It depends!  If your employer offers dental insurance and it’s a PPO plan that you can use anywhere, and your portion of the annual premium is less than $300, then it’s probably worth enrolling in that plan.  Your routine preventive care will be covered at or near 100% which will pay for itself right off the bat.  If you need some minor dental treatment, such as fillings or a deep cleaning, your plan will likely cover the majority of that cost as well.  So insurance through your employer when you have minor dental needs, it’s worth it.  But if you have extensive dental needs (Crowns, root canals, implants, etc) or don’t have dental insurance through your job, dental insurance may not be that beneficial to you.  Most of our patients find that purchasing a private dental insurance plan is more expensive annually than enrolling in our in office membership program.

What are the details of the River Oaks Dental Savings Plan?

For a one time affordable payment, you receive two cleanings or periodontal maintenance visits, two exams, all related x-rays, and one fluoride treatment per year.   You also receive 15% discount off any dental treatment or additional hygiene visits you may require.  There’s no paperwork to fill out, waiting periods, exclusions, or denials.  You don’t have to worry about renewing it- we will remind you when it’s time to renew at your upcoming dental visit.  You don’t have to think about it at all- which is essential in today’s busy world.  You can read more details about the plan here or call 904-348-0416 with any questions you may have about signing up.  

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