Dental Benefit Information

Dental Benefit Information

Dental benefit plans are drastically different from medical insurance plans. Many patients get frustrated trying to navigate their dental plans because of the varying benefits, complicated terminology, and the hassle of spending countless minutes on the phone with someone from their insurance company. Our team at Integrated Dental of Florida can help you understand your plan while maximizing your benefits. If you have any questions about your dental benefit plan, please don’t hesitate to contact us and ask!

It is important to remember that every dental plan varies, so to find out what your unique benefits cover, you’ll need to call your provider directly. The system of dental insurances involves four parties – the patient, the dentist, the dental benefits carrier, and the group or program sponsor (employer). Ultimately, your dental benefit coverage is a negotiated contract between your employer (or you if it is an individual plan) and the insurance company, not Integrated Dental.

At Integrated Dental of Florida, our goal is to make receiving the dental care you need accessible and stress-free. Our team makes insurance easy for all providers – whether we are in-network or out-of-network. We will always complete a complimentary benefit check at each dental appointment and are happy to file all dental claims with supporting documentation.

Have Questions? Contact Our Office!

Important Dental Insurance Terminology

Premium The premium is the monthly or annual amount that you pay for dental benefits through your insurance company or employer.

Deductible The deductible is a set amount of money determined by your insurance company that you’ll be required to pay before your full dental benefits will begin. Typically with dental insurance this amount can range from $25-$100.

Coinsurance The percentage of the costs of services paid by the patient. For example, if the insurance company will pay 80% of the covered services, this creates a 20% coinsurance plus the deductible obligation for the patient. Integrated Dental of Florida will estimate these costs for you prior to the beginning of your treatment.

Annual Maximum The total dollar amount that a plan will pay for dental care per individual during the year. This amount includes the total insurance payouts to all dental service providers. Most dental insurances have a dollar amount limit ranging from $1,000 to $2,000.  This amount is what your insurance will pay for your dental treatments over the course of a benefit year. Note, a benefit year is the 12-month period of dental plan coverage and is typically a calendar year from January to December, but some run on a different 12-month cycle.

In-Network If a dentist is in-network, it means that they have negotiated discounted fees and rates with your insurance company to pass savings on to you.

Out-of-Network A dentist who has not signed up to participate in a specific dental insurance company’s network. This does not mean that you cannot be seen at Integrated Dental of Florida, as a majority of dental benefit plans do have out-of-network benefits.

Covered Service A dental treatment that the patient’s dental insurance has agreed to provide payment for.

Schedule of Benefits A list of dental services and the maximum benefit amounts the insurance company will pay for each service. This schedule will vary not only for each insurance company, but each individual/employer plan within the insurance company.

Exclusions/Limitations Dental insurance plans typically do not cover every dental procedure. Each insurance plan (even within the same insurance company) contains a list of conditions or certain criteria that limit or exclude services from coverage. Limitations may be related to age, time or frequency and exclusions are those dental services not covered by the insurance plan. Some examples of exclusions include the Cone Beam CT, fluoride varnish for adults, dental whitening, cosmetic procedures such as veneers and the use of bone grafting material or PRF (platelet rich fibrin).

Frequencies The number of procedures permitted during a stated period. For example, per the patient’s insurance plan they may have no more than two cleanings in a twelve-month period OR they may only have one cleaning every six months.

Waiting Period A period of time before a patient is eligible to receive benefits for certain treatments. This typically applies to higher end services such as crowns and dentures.

Non-Covered Charges Costs of a patient’s dental treatment that the insurance company does not cover. In some cases, the service is a covered service, but the insurance company is not responsible for the entire charge. In these cases, the patient will be responsible for any charge not covered by the dental insurance plan.

Non-Covered Services These are dental treatments or services not listed as a benefit with the patient’s insurance plan coverage and therefore your dental insurance plan will not pay for them. The patient will be responsible for the entire cost of the non-covered service. For example, with many insurance companies dental implants are a non-covered service.

Maximum Plan Allowance The amount set by the patient’s dental insurance company for a specific procedure. For an in-network dentist, this amount is an agreement between the dental insurance company and the dentist. For an out-of-network dentist, this amount is set solely by the insurance company.

Assignment of Benefits When a member authorizes a dental insurance company to forward payment for a covered dental procedure directly to the dentist. Integrated Dental will accept assignment of benefits with insurance payors that we are in-network with, however, they will not accept assignment of benefits for out-of-network dental insurances.

Coordination of Benefits If a patient has more than one dental plan, this is the process that the plan’s use to determine the amount that each plan will pay for the patient’s dental services.

Explanation of Benefits (EOB) A paper or electronic document provided by the patient’s dental insurance carrier detailing the dental services that were paid for on a patient’s behalf. This is not a bill. A copy is typically sent to both the patient and the treating dentist.

Pre-Treatment Estimate/Preauthorization A treatment plan can be submitted by the dentist to the patient’s insurance carrier to review and provide an estimate of benefits prior to starting the patient’s dental treatment. This can help the patient budget for a dental procedure. Please note, this estimate can take 14-60 days to be processed by the insurance company.

Consultation When you and your dentist discuss your dental goals and dental care.

Diagnostic and Preventative Services A category of dental services that are often paid by the dental plan without deductibles or co-insurances. These services usually include exams, cleanings, and x-rays.

Basic Services A category of dental services that typically includes fillings, extractions, root canals, and periodontal treatments.

Major Services A category of dental services that the coinsurance or copayments are typically higher. These services usually include crowns, dentures, and oral surgery.

Open Enrollment The period of the year during which individuals or employees can enroll or make changes to their dental benefit plan. Prior to changing coverage it is important to note there are several types of dental insurance plans within each individual insurance company. For example, our doctors might be in-network with one Aetna plan, but that does not mean they will be in-network with a different Aetna plan under the same employer. It is important to contact our office prior to changing your plan to ensure that we will still be in-network with your new choice.

Dental Health Maintenance Organization (DMHO) and Dental Exclusive Provider Organization (DEPO) A type of dental plan with comprehensive dental benefits with fixed dollar co-payments. A patient with a DMHO or DEPO must go to an in-network dentist to receive dental benefits from their insurance provider. This type of plan does not reimburse for procedures completed at an out-of-network dentist. Integrated Dental of Florida is not in-network with any DMHO or DEPO dental insurance plans.