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Jacob O. Layer DMD, PC April 2022 Newsletter
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Dental Insurance Realities - Part 5 (conclusion)

Let's conclude our discussion of dental insurance realities with these final topics.

Having more than one dental insurance does not mean that your dental treatment is 100% covered. Intuitively, you'd think someone covered by two benefit plans would mean she'd get two benefit payments, each according to the respective plan's rules, right? After all, each plan is receiving a full premium payment every month. But, in reality, that's not how it works. With dual coverage, one insurance company becomes the 'primary' and the other becomes then 'secondary.' It's not clear how the primary/secondary designation is made. The benefit plan in the 'primary' position typically behaves like a normal dental benefit plan: a claim is submitted and the payment is received. However, the 'secondary' plan's behavior is much less predictable. They may pay well or not pay at all. Typically the secondary does not pay until after the primary has paid its portion and a second claim is submitted to the secondary. In our experience, it is essentially impossible to get a pre-determination from a secondary benefit plan.

Regarding the annual maximum: Most plans have an annual maximum of $1,000-1,500. That means that the maximum benefit per year that the plan will pay toward dental treatment is $1,000-1,500. Even if the company says, "we cover 50% of ______ procedure, bear in mind that is true but only up to the maximum. Let's consider this example: Jane needs a root canal ($1000) and a crown ($1,900). Her benefit plan contract says they will pay 50% toward each procedure. Half of her root canal and crown may be paid for by her benefit plan (it's within her $1,500 annual maximum) leaving a small amount leftover. When it comes to the bridge, even though the plan "covers" 50% of the bridge there is only a small amount left in this year's annual maximum. Jane pays for the remainder herself. When some of the needed dental treatment is completed by a specialist, that treatment is billed to the benefit plan using the same annual maximum amount. It can be difficult for each office to accurately account for the remaining benefit in that scenario. When that happens it's difficult to estimate the out-of-pocket expense. Recently we are seeing a few plans that report having *no annual maximum* to them. This sounds great, right? Well, the truth is that these plans have lots of 'red-tape': exclusions, restrictions, or other barriers to using the plan effectively. Grandma always said, "If it sounds too good to be true..."

We as a provider call requesting information on behalf of our patients as a courtesy. We do this a lot. We get basic plan information. Sometimes what we are told is accurate. Other times it's wrong. And sometimes we're told one thing and then the patient is told something else. We generally feel that the policyholder will get more accurate information than the provider will. And yes, we do see miscommunication result in claim denial and even delays in completing treatment.

More and more dental benefit plans include a waiting period. This is a relatively new phenomenon and seemed to begin shortly after Obamacare first came on the scene. The waiting period stipulates that the benefit plan company wants to receive premium payments from you for a certain number of months before you get to use any benefits.

Insurance benefit plans change from time to time. It is in the best interest of the plan to reserve the ability to make changes from time to time. Contract language to that effect is included in every benefit plan. That makes sense as long as the plan follows its own rules for notifying the policyholder. It's common for us to talk with patients who don't know that a change has occurred or exactly what aspects of the plan have changed. Sometimes the out-of-pocket cost to the patient can go up dramatically because of changes in plan language. Other times certain procedures are removed from the list of 'covered' services and options are restricted.

Sometimes an insurance company will deny a claim inexplicably. On otherwise routine dental work we simply get a notice from the insurance company stating that they're not paying anything. Sometimes a reason is given and other times no reason is stated. Of course, we send narratives, x-rays, photos, and other information which is intended to provide additional information substantiating the benefit claim. Occasionally, we get stonewalled and the patient is left holding the bag. We don't like it either.

We've talked a lot about the realities of so-called dental insurance. We prefer to think of them as 'benefit plans' instead since they don't work the way normal insurance does. Be sure to know your plan, know the annual maximum, know what contribution you can expect, and remember that it might not "cover" everything you need. Is a dental benefit plan a good addition to your financial plan? We hope this series of articles has helped you choose.

Happy Spring…… Cleaning!
Cherry Blossoms Blooming on branch in spring
Trees are getting their leaves back and flowers are starting to bloom; it must be spring! With spring comes – you guessed it – spring cleaning! Wahoo! In the midst of taking those old clothes to charity or setting up those garage sales, don't forget your toothbrush! I'm NOT saying you should donate it though (except maybe to the nearest garbage can). Studies show that the majority of Americans replace their toothbrushes every 9 months, while only 9% replace them regularly. I'm sure you've heard the old adage, "change your toothbrush every three months", but have you been told WHY that's important?
Like everything in life, toothbrushes wear out. A new toothbrush has clean bristles with rounded edges and, when used properly, can gently sweep away plaque, bacteria and food debris without causing damage to the teeth or gums. Older toothbrushes, however, often have broken, frayed and sometimes sharp edges making them less effective at removing plaque and likely to cause gum damage. Also, aging toothbrushes harbor bacteria, viruses, and fungus. I won't tell you what the Mythbusters found on their toothbrush experiment! Yuck!
Don't fret though; you can retire your old toothbrushes to other jobs like scouring tile grout, staking up a new plant, cleaning jewelry, or combing eyebrows and removing clumps of mascara.
So there ya go. For the sake of your smile, change your toothbrush every season. Good luck with those garage sales and Happy Spring!
- Jocelyn Codington RDH

Last Newsletter But...

Layerdental Family -

I've been doing this regular email newsletter for several years. Well, now it's time for me to put my attention into content in other areas. Please accept my sincere gratitude for inviting our newsletter content into your lives and hearts! I hope that it has been helpful, informative, and a little entertaining.

And now, I look forward to continuing to connect with you more via social media! You can find us on Instagram @layerdental and on Facebook at layerdental.

None of our contact information has changed. Our office location is still 1485E. McAndrews Rd in Medford. Our phone numbers and email addresses are the same as they've always been.

I look forward to many more years serving you!

-Dr. Jake

Dr. Jake and his Team would love to hear from you! Got a question? We can help!

Jacob O. Layer DMD, PC | layerdental.com | 541-734-0970
1485 East McAndrews Rd., Medford, OR 97504



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