How Dental Benefits Work

Whether you are new to our practice or have been a valued patient for years, it is important to know how your dental benefits work. Our team would like to explain how most dental plans work, and why only select services are covered.

Dental benefits can make it easier to get the dental care you need, however, most dental plans do not cover 100 percent of the treatments you need. Most dental plans are a result of a contract between the insurance company and your employer, union, or association. Your dental coverage reflects how much your employer pays into the plan. Therefore, when deciding on treatment, your dental benefits shouldn’t be the only thing you consider. You and your dentist should work together to create a custom treatment plan that benefits your health. Our primary goal is to help you take care of you. We want your teeth to last a lifetime and maintain good overall health.

Types of Dental Plans:

HMO Plans

There are typically two types of care plans which include both HMO and PPO. If you have an HMO, you are required to go to someone on a list of HMO providers with your insurance (in-network). At La Jolla, we do not accept HMO plans. Often patients will ask why, and the reality of it is that HMO plans were created so insurance companies could pay less for necessary dental treatment. By paying less, the dentist needs to be willing to accept less, cutting into one-on-one time with patients and seeing more patients on any given day. Here at La Jolla Cosmetic Dentistry and Orthodontics, we are not willing to jeopardize our mission to provide quality patient care; therefore, we do not accept any HMO plans.

PPO Plans

A PPO plan is designed to offer patients the freedom to choose their dentist. It is sometimes beneficial to go to an in-network provider for additional savings. We accept all PPO plans here at La Jolla and are currently in-network with the following:

  • Delta Dental PPO
  • Assurant/DHA
  • MetLife Dental PPO
  • Connection Dental Network
  • Humana Dental PPO
  • First Dental Health PPO
  • Cigna Dental PPO
  • Maverest Dental Network

If you have a PPO plan and the company is not listed above, that does not mean we are an out of network provider for your plan. All of the above companies are affiliated with other dental companies, so it’s possible we could be in-network for you. So please call and discuss with our insurance coordinator to see if that is the case.

Limitations and Exclusion of Your Dental Plan

All dental benefits have limitations and exclusions. Several things factor in when calculating dental benefits for patients. If you would like an estimate, please request that a pre-authorization with our team. It is important to know that there is never a guarantee with pre-authorizations but this can be helpful in making financial arrangements.

Most plans have a maximum benefit, which means there is a maximum amount the company will pay out each year for dental treatment. This maximum is typically per person, per year. Except for the orthodontic maximum, which is usually a lifetime benefit, this does not renew each year. Most plans also have a yearly deductible. This deductible usually comes out of dental treatment such as fillings, crowns, etc. However, it can come out of your allowance for annual cleanings.

There are also frequency limitations on most plans limiting the recurring payments times insurance companies will pay for treatment. An example of this would be cleanings; some companies will cover two cleanings each year, but other could offer more. Many plans require these recurring cleanings to be at least six months apart, but others do not need time in between treatments. Services such as exams, x-rays, fillings, and crowns are in the same category. Due to all of the extent of limitations with dental benefits, we can only estimate what your dental benefits plan will cover; we cannot guarantee any benefit.

We hope that this information is helpful and we encourage you to please give our office a call with any questions you may have at 858-295-0603.