“Why Does My Dental Insurance Not Cover That?”

This is probably one of the most common questions patients ask. The answer relates to the specifics of each plan (every plan is different).

A familiar specific is called “Frequency”. This will limit the number of times your insurance will pay for a procedure. A common limit will be the number of times your insurance will pay for a dental cleaning. Some plans will pay at six (6) month intervals only (if you are a day short of 6 months, your insurance will not pay for your cleaning). Other plans will pay for two(2) cleanings over any consecutive twelve (12) months (so you need to keep track of each cleaning to determine if it will be covered [sometimes tricky]). Some other plans will pay for two (2) cleanings two times per year, and at any time (you may have your teeth cleaned two times in one month if you desire, then your coverage is complete until your plan renews for the following year). There are some generous plans which will cover cleanings three (3) or four (4) times per year, and there are even some plans that have no Frequency Limits on cleanings.

Another common limit will be the number of times your insurance will pay for exams. Some plans will cover only two (2) exams per year (which is fine when you are in your dental office only two times per year for regular check-ups and cleanings. However, if you experience a toothache during that year and you need to see your dentist, the insurance will not pay for your exam if it has already paid for two exams). Other plans may cover two(2) regular exams, plus two(2) limited exams for toothaches. There are some plans that have no Frequency Limits on your exams.

Although it is disappointing when your insurance denies payment, it is important to remember that you may need services not covered by your plan. Health and preventive-oriented dental professionals will always focus on your individual needs and recommend treatment to help you keep a healthy, beautiful smile. When you choose not to accept recommended treatment simply because your insurance will not cover it, you need to accept the responsibility for that decision, and possibly a lower level of health.

Who determines the Frequency Limits on a plan? Your employer will make this decision (or you will, if you have your own personal plan). A general “rule of thumb” regarding coverage: the plans which have the best coverage are also the more expensive plans. From a business standpoint, there are times when the costs associated with employee benefits must be considered. Every business monitors its overhead costs and balances these costs on a continual basis. This balancing act is no easy task.

When you experience some disappointment regarding a “denied dental claim” it will be important to remember that you and your dentist are partners in deciding your dental future. After all, what else can impact your life as much regarding your enjoyment of meals, your conversations, your smile and, don’t forget, your kiss!

Stay tuned for more about your insurance.

Roger D. Nishimura DDS, Scott J. Anderson DDS and staff