Our goal is to ensure that you are offered the best dental health possible. Dental benefits were never meant to provide the best possible care – they are there to assist you in the treatment of choice. Remember – a dental insurance plan is not a treatment plan!

Navigating through dental insurance plans can be foreign for many, especially for those using their benefits for the first time. It’s important to have an idea of your dental coverage ahead of a scheduled appointment, but insurance jargon can get a little confusing!  If you would like to get a clearer understanding of how dental insurance works, keep reading. Please keep in mind that this post is here to help answer general questions – your employer and an insurance representative can answer questions that relate specifically to your plan.

What is the patient responsible for?

Insurance coverage is an agreement between the insurance company and the place of employment. In Ontario alone, there are over 30,000 dental insurance plans that are unique in their benefits! Some plans cover as much as 100%, while others cover as little as 10%. This is why it is important to have an understanding of your plan ahead of scheduling an appointment.  It is also important to be aware that your coverage may not be based on the current year’s fee guide (our office follows the current Ontario Dental Association fee guide), and the amount of coverage negotiated with your insurance company does not involve the dentist. This means patients are responsible for unpaid portions of dental procedures (co-payment). Patients are expected to cover the costs of any procedures that the insurance plan does not cover.

Waiving the co-payment is forbidden. Contrary to what some patients believe, dentists cannot waive the co-payment fee as this is insurance fraud. Insurance fraud can lead to very serious consequences.

What is the dental office responsible for?

The dental office will provide you with the available treatment options that address your dental care needs. This treatment plan is based on the condition of your dental health, and not the frequencies/limitations of your dental plan. Dental pre-determinations, also known as dental estimates, can be submitted by the dental office to your insurance provider. Pre-determinations can be thought of as a request to insurance providers, asking them to notify the patient what they should expect to be covered for procedures in the treatment plan. Due to privacy laws, the insured member will receive the response and not the dental office. Therefore, the patient is responsible for checking their pre-determination responses, and knowing their coverage prior to an appointment.

There some cases where the insurance provider will contact the plan administrator for additional information. The plan administrator will then ask you to request this information from your dentist. The dental office will provide you with the information you request, but it is ultimately your responsibility to provide this information to your plan administrator.

 

Paying upfront vs. Paying the difference

It is common for patients to wonder if they are expected to pay upfront for dental treatment (and get reimbursed by their insurance) or if they should simply pay the difference. This depends on the plan – some plans allow assignment of benefits (paying the difference) while others are non-assignment (paying upfront). While there are dental practices that do not accept assignment of benefits, our office does. Again, this depends on your plan – if your plan allows assignment of benefits, our reception team can help submit dental claims and collect the out-of-pocket portion not covered by the dental plan.

Primary and Secondary Insurance

Some patients are covered under two insurances. Please let reception know if you are enrolled under your partner’s plan (in addition to your own). If you are a student (over 18) under a parent’s plan, please make sure you inform reception of the academic institution you attend, and whether you are a part-time or a full-time student.

At the completion of an appointment, our reception team will send out a claim to your primary insurance provider. If the primary insurance is covering less than 100% of the services, the response received will then be submitted to the secondary carrier. The secondary insurance will need to consider the primary coverage in order to assess the claim. The patient is responsible for any remaining balance not covered by both insurance plans.

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If you have more questions related to your dental coverage, your employer and/or insurance provider can answer any specific questions. For general information, click here to visit the Ontario Dental Association’s website.

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