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Dental insurance question...help needed

Posted by on Mar. 15, 2015 at 1:32 AM
  • 23 Replies

I am on medicare and pay a premium for my benefits to be administered by a private insurance company. I pay the $104 for basic medicare plus $87 for the upgrade, plus $12 a month for a dental add on and then $26 for my prescription coverage. I understand how the health and prescription programs work--they are great. My question is on the dental coverage.

I have $1000 a year in maximum dental benefits. The schedule lists certain procedures and the amount I will pay (copay). My question is how is the $1000 determined. I called the company, but the 2 reps I talked to acted like I was speaking Mandarin or Russian. The schedule says that I will pay $18 per tooth extraction; 0 for bite wing x-rays; top dentures $398; lower dentures $398. How do I know how much is applied to the $1000 annual maximum benefit?  I need all remaining teeth pulled and dentures. 

Any clues?

by on Mar. 15, 2015 at 1:32 AM
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Replies (1-10):
fairymom82
by Ruby Member on Mar. 15, 2015 at 2:09 AM
1 mom liked this
No clue but I will ask my Dad for you tomorrow. He helps at the VFW and Eagles club with the understanding and explanations for the elderly community
jjames1990
by on Mar. 15, 2015 at 2:12 AM
The amount they pay the dentist is what I'd applied to the max allowed. So when you have a procedure you need to fine out what the dentist will get paid per their fee scheduled contract with the insurance company.
Spam72
by Emerald Member on Mar. 15, 2015 at 2:14 AM
They will pay $1000 a year for you. Anything after that you pay.
tossed
by Ruby Member on Mar. 15, 2015 at 2:16 AM

I understand that, but how do they calculate the $1000. I know my portion and they obviously have a contract with the approved dentists, but how do I know how much an extraction will deduct from the $1000. The 2 company reps could not answer that question. 

Quoting Spam72: They will pay $1000 a year for you. Anything after that you pay.


tossed
by Ruby Member on Mar. 15, 2015 at 2:19 AM


Quoting jjames1990: The amount they pay the dentist is what I'd applied to the max allowed. So when you have a procedure you need to fine out what the dentist will get paid per their fee scheduled contract with the insurance company.

This is what I think as well, but need to know in advance because that will help me decide on what procedures to have done. With the current rates, an upper denture could be over $1000 in my area...I don't want all of my teeth pulled just to be told, you are out of benefits.  It would help if they would list a schedule that says "This is your copay per procedure; this is the amount that is applied to your $1000). 

JakobLukasMom
by Silver Member on Mar. 15, 2015 at 2:21 AM
2 moms liked this
Have the dentist do a pretreatment estimate and send it to the insurance, then the insurance will send you a statement indicating how much they will cover.
jjames1990
by on Mar. 15, 2015 at 2:25 AM
1 mom liked this
They can't because each dentist had a specific contracted amount per area. You will need to shop around for dentist and ask then what will be your out of pocket and how much will go to your max.

Its annoying I know. Good luck. I suggest looking into a second dental insurance as a secondary coverage. You can get a low cost monthly premium and it will assist with the max allowed and copayment.

Quoting tossed:

Quoting jjames1990: The amount they pay the dentist is what I'd applied to the max allowed. So when you have a procedure you need to fine out what the dentist will get paid per their fee scheduled contract with the insurance company.

This is what I think as well, but need to know in advance because that will help me decide on what procedures to have done. With the current rates, an upper denture could be over $1000 in my area...I don't want all of my teeth pulled just to be told, you are out of benefits.  It would help if they would list a schedule that says "This is your copay per procedure; this is the amount that is applied to your $1000). 

wooly
by Knitting Maniac on Mar. 15, 2015 at 2:28 AM

When I needed major work done, mine was restoreative, not extraction. My dentist and I worked out a plan where he went up to my dental max and then we waited until the next year to start up again. You need to consult with your dentists staff and the dentist to see what all is needed and how much your ins will pay each year.

tossed
by Ruby Member on Mar. 15, 2015 at 2:33 AM

The out of pocket is set by the insurance company. I know that amount because there is a published schedule--no matter which of their dentists I see, it is the same out of pocket.  All of the secondary insurances I have checked require waiting a year before they will pay for major procedures like dentures. The other issue is that the dentists on those plans are not the ones approved on my plan, so it would be hard to coordinate care. I also ran into a problem because the only dentists I found available on the dental plans in the area are bottom level dentists with pretty bad reps. Thanks for your help. I think I will call again and see what I can find. 

Quoting jjames1990: They can't because each dentist had a specific contracted amount per area. You will need to shop around for dentist and ask then what will be your out of pocket and how much will go to your max. Its annoying I know. Good luck. I suggest looking into a second dental insurance as a secondary coverage. You can get a low cost monthly premium and it will assist with the max allowed and copayment.
Quoting tossed:

Quoting jjames1990: The amount they pay the dentist is what I'd applied to the max allowed. So when you have a procedure you need to fine out what the dentist will get paid per their fee scheduled contract with the insurance company.

This is what I think as well, but need to know in advance because that will help me decide on what procedures to have done. With the current rates, an upper denture could be over $1000 in my area...I don't want all of my teeth pulled just to be told, you are out of benefits.  It would help if they would list a schedule that says "This is your copay per procedure; this is the amount that is applied to your $1000). 


Char-Bear
by Platinum Member on Mar. 15, 2015 at 2:35 AM
Contracts vary by provider so the reimbursement amount is different. Ask your dentist for a pretreatment estimate, that will give you an idea of how much will be covered under your max. If you are having surgical extractions those might fall under your medical benefits and the estimate should tell you that.
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