Insurance

You can always check with your insurance company to find out what they are and how much they cover. We can also help! A member of our team can get a breakdown of your benefits. We’ll just need some information, including your carrier name and subscriber ID.

Being out of network simply means our office does not have a direct contract with your insurance provider. It does not mean we don’t take your insurance. For those carriers that we do have a direct contract with, they have in-network fees. When out of network, we use the base price for the service and apply the coverage percentages that correspond to your out-of-network benefits to calculate what you’ll owe. We accept major PPO insurances. We are not contracted with Denti-Cal, Medi-cal, or HMO plans.

The basic premise of dental insurance is the same as other types of employer-provided insurances such as Medical and Vision. Most dental insurance is provided by your employer, has monthly premiums associated with that coverage, has guidelines on who you can see, and differences in benefits provided. The major difference with dental insurance is that the insurance provider has a yearly maximum they will reimburse, whereas a medical insurance provider covers reimbursement after the individual reaches their own out of pocket maximum.

Dental insurance works similarly to your medical insurance, with the main difference that the insurance provider is responsible for “first money out”, meaning they cover up to a “maximum allowable” amount in a given benefit period (usually a year) and the patient is responsible for any amount over that limit. The maximum allowable amount is unique to your insurance plan and is important to know what it is when seeking more costly care. Further, as with medical co-insurance, dental PPO plans typically cover services based on ranges or categories: preventive, basic, and major. As an example, many PPO coverages provide 100% coverage for preventive services, 80% coverage on basic services, and 50% for major services. This break down is plan-specific and you will need to consult your personal benefits to understand your coverage. What is not covered by your insurance is the patient’s responsibility.

Typically, dental insurance covers all types of dental care ranging from exams and cleanings (typically 2x/year), basic dental care (fillings, crowns, etc.) to oral surgery and orthodontics. Insurances categorize each type of care into preventive, basic, and major services and each is covered at a determined percentage, leaving the remaining balance to the patient (typical breakouts are 100%/80%/50% for the coverage percent ages). Orthodontics are unique and typically have rules around age, who on your plan is allowed to use, and how much is offered. In general, with orthodontic coverage, there is a lifetime maximum versus and annual amount.

A PPO is a “preferred provider organization”. PPOs do not require you to choose a primary dentist. You don’t need referrals to see a specialist, either, but you will likely save money if you see one in your plan’s network. PPOs differ from HMO/ DHMO insurance plans that typically cover dental services at a low cost and minimal or no copayments with a pre-selected primary care dentist or a dentist facility with multiple dentists. With HMO/DHMO plans, you are required to select a primary dentist and are restricted to that dentist unless otherwise referred to a specialist.

In most cases, PPO plans cover two exams and cleanings in a calendar year.

In most cases, yes. However, there are exceptions and rules that are important to know prior to care. For instance, a dental implant would not be covered if you were previously missing your tooth and your coverage includes a “missing tooth clause”. We can help you get information on what rules are in place for you rspecific coverage.

In most cases, yes. Orthodontics are unique and typically have rules around age, who on your plan is allowed to use, and how much is offered. In general, with orthodontic coverage, there is a lifetime maximum versus and annual amount. We can help you get information on what rules are in place for your specific coverage.