Skip to content

Dental Insurance Plans – How They Work?

Posted in Dental Care, General Dentistry, and Studentcare Network

Common to All Dental Insurance Plans

In Ontario there are thousands of different dental plans. Everyone has different needs, making it impossible to have just one plan for all. Although, there are somethings common to all dental insurance plans.

  • Your dental insurance provider or your employer can explain coverage details. It should be clear what is covered and what is not.
  • Ultimately, you are responsible for making sure the dentist is paid for their services.
  • Co-payment is the percentage of your bill not paid by insurance. (Usually 10-50%)
  • Your treatment options are always determined by your needs, not your insurance coverage.

Work Together with Your Dentist

Your dentist is your ally. Together, you both work towards excellent dental health. As a team, understand your benefits, your roles, and your responsibilities. If you have questions about the cost of dental services, ask your dentist. At Erbsville Dental there are staff dedicated to assisting you and they will speak directly with your insurance company if needed. And Dr. Mathews will always give you a clear and precise answer about costs and treatment options if you are interested.

Know Your Options

Most dental plans are provided by the company you work for. Those without benefits can purchase dental insurance. Some dental plans are available for students and others are government run for select groups of people. It’s always smart to research what’s available to you. Like anything we buy, there are good products and others less desirable. Do not assume your dentist knows everything about your plan. Research insurance documents and digital documentation and get to know your coverage. Also, research the insurance company and their reputation. Testimonials and reviews can help you considerably.

Questions to Ask of Your Plan:

  • Co-payment – What percentage am I responsible to pay?
  • How many cleanings and X-rays can I have?
  • What is my coverage for fillings and root canals?
  • Am I covered for bridges and crowns, dentures, and oral surgery?
  • What is covered each year?
  • Is there a deductible on some or all dental services?
  • Is there a total dollar limit on my coverage?
  • Can I choose a procedure other than the one my plan covers?
  • Is my coverage transferable if I change jobs?

Communicate With Your Employer

When a company is buying a plan for their employee’s they of course think of how it will benefit their workers and their families. They also must be concerned about cost. Once a plan is chosen, the insurance company becomes the plan administrator. Although the employer is not responsible as a plan administrator, they will want to know if they are getting good value for their money. They ultimately can change insurance companies if too many issues arise. Your plan administrator or insurance company is responsible for reimbursing you based on the terms of the dental plan contract. Let your employer know if you have to fight for things, you clearly should be covered for. They ultimately have the power to do something about it.

With thousands of plans comes hundreds of payment options. Some plans require you to pay the dentist out of pocket and then reimburse you later. Many will pay the dentist directly. Still others, implement a cost-sharing compromise between you and your employer where you pay part, and your plan pays the balance.

Avoid Insurance Fraud

When it comes to the co-payment or percentage of the bill your coverage requires you to pay, there is an important thing to understand. Even if they wanted to your dentist legally can not waive the co-payment. Doing so is considered insurance fraud. The insurance company pays it’s part of the bill assuming you will do the same and thus both fulfill the terms of the plan contract. Any dentist who does this could be fined or loose their license.

Dentist Responsibilities

As we discussed briefly, treatment plans are based on your needs as a patient not what’s available to you by insurance coverage. Dentists are responsible to explain any treatment plans they design, and answer your questions including ones about cost. If required a pre-treatment plan can be submitted to your insurance company before proceeding with a treatment plan. Doing so can identify any limitations in coverage and clearly outline any personal costs you would be responsible for.

If you want to know more about your dentists’ responsibilities related to fees, they are outlined clearly by the Royal College of Dental Surgeons of Ontario who are also the regulating authority for Ontario dentists.