Coverages can be confusing when it comes to the amount they pay 

Like many types of insurance, dental insurance can be a big help at times and come up maddeningly short other times. We see all levels of dental coverage at Janssen Dental Clinic, and our best advice is to take the time to clearly understand what your policy provides. You might be surprised.

You would think dental insurance and medical insurance would be similar products, when in fact they operate very differently. Medical insurance typically offers a high dollar amount of coverage after you meet your deductible, while dental insurance provides limited coverage with the benefit of lower deductibles.

Take a look at your dental insurance policy language to see what your maximum coverage amount is. It is not uncommon for dental plans to cover a maximum of only $500 to $2,000 of usual and customary costs. And therein lies the next riddle…

What are “usual and customary costs” for dental insurance?

This is a key term within your dental insurance policy language. Usual and customary costs are what the insurance company deems your procedure should cost, not what it actually does cost. Most insurance companies are still operating under usual and customary cost figures that were established decades ago, numbers that are far removed from today’s reality.

Unfortunately for you as the policyholder, that means you are on the hook for the difference. This can be especially confusing when your policy states you have 100% coverage for usual and customary costs. At first glance, that makes it sound like procedures such as your regular cleanings will be completely covered. But if the cost of your cleaning is $100, for example, and the insurance company still thinks it should cost $80 like it did 20 years ago, then you need to pay the $20 difference.

The differences between real procedure costs and what the insurance company deems as usual and customary costs can expand greatly for more advanced procedures. Maximum coverage limits may come into play as well.

How can you see what the usual and customary costs are?

Many insurance companies will not tell you what their usual and customary costs are (unless the plan is a fee schedule). Instead, they prefer to have dental offices obtain preauthorizations for patients prior to treatments, often delaying our ability to provide needed treatment for several weeks.

While insurance companies recommend preauthorizations to get a better idea of how they will pay for treatments, they are still not a guarantee of payment. In fact, the majority of preauthorizations include language on the bottom stating, “A preauthorization is not a guarantee of payment.” This gives insurance companies the flexibility to change their minds on coverage at any time.

Are in-network or out-of-network providers better?

Here is another difference from health insurance, where receiving treatment from in-network providers usually is the better option for patients. When it comes to dental insurance, out-of-network providers often are the better option because they do not have contracts with the insurance companies that require them to write off some procedure costs.

As a result, out-of-network providers usually are able to provide higher-quality materials, newer technology, and the most up-to-date dental information for their patients. Most dental insurance plans allow you to access out-of-network providers, and the benefits are the same most of the time anyway. In either case, insurance will cover only up to the maximum amount allowed under the policy language.

About Janssen Dental Clinic in Green Bay, Wisconsin 

Janssen Dental Clinic features the dental expertise of Dr. Craig Janssen, a third-generation dentist serving patients in Green Bay, Wisconsin, and the surrounding area. Dr. Craig and his staff specialize in oral health as a component of overall well-being, a philosophy of care known as biological dentistry. They have expertise in reducing the fear and anxiety that people of all ages feel over going to the dentist, with services ranging from routine cleanings to restorative and cosmetic procedures. Call (920) 983-8383 to schedule an appointment. New patients are always welcome.