Don’t Let Your Dental Insurance Benefits Decay
Understanding Dental Insurance Matters
Dental insurance can make your care more accessible and affordable—but only if you truly understand and use your benefits! At Kelner Periodontics in Clark, NJ, we help our patients make fully informed decisions about every aspect of their dental care. That’s why we’ve put together this comprehensive guide on dental insurance.
Should you use an employer-based plan, try to find an insurance plan yourself, or go without insurance?
Most people don’t know. This guide will help you make the right choice and maximize your dental insurance coverage.
Why Doesn’t Dental Insurance Work Like Medical Insurance?
One of the first questions many patients ask is, “Why doesn’t my dental insurance cover everything like my medical insurance?” The truth is that dental insurance and medical insurance operate on very different models—mainly because medical premiums tend to be much higher (typically, 10 to 20 times more) than dental premiums.
Medical Insurance Benefits
Most medical plans provide extensive coverage for big expenses, such as surgeries, hospital stays, or treatment for critical illnesses. Routine care often comes with out-of-pocket costs. If you have a lower-cost plan, the deductible may be quite high before your coverage kicks in.
Dental Insurance Benefits
Dental coverage tends to help with smaller, more frequent procedures—like cleanings or fillings—but it typically has a limited annual maximum (often between $1,000 and $2,000). Once you exceed that maximum, you pay the full cost until your plan resets. Preventive cleanings might be covered at or near 100%, while specialized services—such as periodontal procedures—may require copays, deductibles, or be covered at a lower percentage. Understanding this difference will help you manage expectations. While you may not see the same level of coverage for extensive dental treatments, there are still ways to optimize your dental coverage so you’re not leaving valuable benefits on the table.
Major Dental Insurance Providers in New Jersey
New Jersey has a variety of dental insurance providers offering different tiers of coverage and plan designs. Some of the larger dental insurance providers are: • Aetna Dental • Careington • Cigna Dental • Delta Dental • Guardian Dental • Horizon Blue Cross Blue Shield of New Jersey • MetLife Dental
If you already have coverage, review your plan’s fine print—especially for specialty procedures like periodontal treatments—and note any waiting periods or in-network vs. out-of-network stipulations. If you’re searching for a plan, these providers are a good starting point. Feel free to ask us which plan may best cover your specific periodontal needs.
Employer-Based, Individual, or No Insurance: Which Is Right for You?
There’s no one-size-fits-all approach to dental coverage. Each option—employer-based group plans, individual plans, or going without insurance—has pros and cons.
| Insurance Type | Advantages | Best for People Who… | Be Aware… |
|---|---|---|---|
| Employer-Based |
- Typically, lower premiums due to group rates - Often, no waiting periods for major procedures |
- Get routine care - Don’t have specific needs |
- If your employment is terminated, you can continue coverage under COBRA, but it may be expensive |
| Individual |
- Independent (not tied to employer) - Flexible (can match plan to your needs) |
- Are able to anticipate the treatments they will need for the next year - Prefer specialized or high-end coverage if not offered by employer |
- Waiting periods may apply before you can access benefits |
| No Insurance |
- No monthly premiums - No restrictions |
- Rarely need more than preventive care - Are willing and able to pay out-of-pocket for unanticipated problems |
- You may pay a higher rate than what insurance carriers have negotiated |
If you have ongoing or chronic gum issues, even basic dental insurance can be beneficial. If you choose to pay out-of-pocket, ask about payment plans or special financing. Many practices, including Kelner Periodontics, can help you explore these options.
Getting the Most Out of Your Dental Insurance
Each dental plan operates on an annual cycle, usually resetting at the start of the calendar year (or on your plan’s renewal date). Know your plan’s timing to avoid losing unused benefits when the cycle resets.
Know Your Coverage Year and Annual Maximum
Your annual maximum is the total amount your insurance will pay in a benefit year. If your plan covers $1,500 and you need more than that, you pay the difference out of pocket. Once the plan renews, you have a fresh $1,500 to work with—but any unused funds from the previous year disappear!
Don’t skip preventive visits, even if they’re not covered at 100%; improper dental care can lead to more costly restorative treatment.
How is preventive coverage defined?
Most dental plans cover cleanings, exams, and X-rays at or near 100% as preventive coverage. Staying on top of these preventive services can help you catch gum disease early—potentially saving you from bigger bills later.
How do waiting periods affect major services? Major services like periodontal surgery or dental implants often come with a waiting period (6 to 12 months) before non-preventive work is covered. If you’re switching plans or signing up for the first time, be aware that you can’t always dive right into major treatments immediately.
Coordinating Care to Maximize Your Benefits
Navigating your dental insurance can feel like a balancing act, especially when more than one specialist is involved in your treatment plan. However, with a little foresight and open communication, you can optimize your coverage and minimize out-of-pocket costs—particularly if you need periodontal care alongside other procedures, such as implants or prosthodontic work.
1. Time Your Procedures Wisely
…but don’t put off necessary treatment. The sooner you get the care you need, the quicker you will be able to enjoy a beautiful, healthy smile. Putting off needed work can increase the severity of existing problems, risk of complications, needing additional treatment, and out-of-pocket cost.
Most dental plans reset on January 1 or on your policy’s anniversary date. If you know you’ll need multiple treatments—like a bone graft with a periodontist and then a crown or implant restoration with a prosthodontist—make sure to start treatment before your current-period benefits expire. For example, start preparatory work (like gum or bone treatments) by November or December, then finish the crown or implant placement in January or February. Splitting the procedures across two plan years can help you tap into two sets of annual maximums instead of exhausting just one. However, don’t put off the start of treatment for the end of the year to try and save money without consulting your dentist. And, especially if your treatment involves multiple providers, plan ahead as much as possible. You don’t want any issues (e.g., scheduling, approvals) to delay your treatment past the current benefit period.
2. Real-Life Savings Scenarios
Imagine you have a $1,500 annual maximum and need a periodontal procedure costing $2,000 plus an implant restoration at another office for $1,500. Doing both in the same benefit period could push you well beyond $1,500 in out-of-pocket expenses. But by spacing your periodontal work late in the current year and scheduling the implant restoration early in the next year, you could take advantage of two separate $1,500 maximums—significantly reducing your total costs. Small timing decisions like this can lead to big savings while still keeping your oral health on track.
3. Coordinating Across Multiple Specialists When your treatment involves a periodontist, general dentist, and possibly a prosthodontist, it’s important to keep everyone informed about your insurance details and the timeline of each procedure. • No Overlap on Your Benefits: Each specialist needs to know how much of your annual maximum remains, so you don’t run out unexpectedly. • Right Procedures, Right Order: Successive steps often depend on proper healing from the previous procedure—another reason clear communication matters. • Fewer Surprises: By sharing treatment plans, X-rays, and insurance breakdowns, your care team can confirm coverage and submit accurate pre-estimates. If you’re ever unsure about your plan or need help synchronizing visits, reach out to your dental providers—including Kelner Periodontics. Our team can handle the insurance paperwork so you can focus on what matters most: your oral health.
Why See a Periodontist (and Not Just a General Dentist)?
A common misconception is that specialists cost more. Your insurance often covers the work performed by a specialist at the same or similar rate to what you’d pay at a general dentist’s office. However, you’ll gain the benefit of a specialist’s expertise, training, and experience.
Specialized Training
Specialists, like periodontists, complete an additional three years of university training after dental school. Periodontists focus on the prevention, diagnosis, and treatment of gum disease, as well as implant placement. By seeing a specialist, you benefit from that extensive training and experience, which can lead to better outcomes and potentially lower long-term costs.
Comprehensive Gum Care
Gum health is crucial. Advanced periodontal disease can result in tooth loss and may even affect overall health. At Kelner Periodontics, we offer bone grafts, gum grafts, deep cleanings, and other tailored treatments. Tackling gum issues early can save you money (and discomfort) down the line—even if insurance covers only part of the cost.
The Importance of a Predetermination of Benefits
Before starting any significant dental procedure—like periodontal surgery, implant placement, or bone grafting—it’s a good idea to get a predetermination of benefits from your insurer. At Kelner Periodontics, we routinely handle this for our patients. What Is a Predetermination of Benefits? Sometimes called a “pre-D,” a predetermination is a written outline from your insurer explaining how much of a procedure they’ll cover and what your financial responsibility will be. It’s not a guarantee of payment—plan details and treatment needs can change—but it gives you clear idea of the costs you should expect in advance of committing to anything. Your dental care provider should be able to tell you if any complications are likely.
Common Questions About Dental Insurance
Can I Switch Plans Mid-Year?
Usually, you can only switch during open enrollment or after a qualifying life event (marriage, job loss, etc.). Doing so may reset waiting periods or deductibles. What If My Procedure Is Deemed Cosmetic? Insurers often classify treatments like teeth whitening or cosmetic gum reshaping as elective and won’t cover them. Your dentist or periodontist will let you know if a procedure is cosmetic rather than restorative.
Are There Alternatives if My Insurance Doesn’t Cover Everything? Ask about payment plans, financing options like CareCredit, or in-house dental membership programs. These can offset costs if you lack coverage or your plan doesn’t cover certain procedures.
How do dental specialists set their fees?
Dental specialists, including periodontists, consider the complexity of each procedure, the cost of materials and technology, and their additional years of training when determining fees. However, if a practice is “in-network” for a particular insurance plan, the fees for covered procedures are set by a negotiated fee schedule. This is a contract between the dental office and the insurance company per plan.
Dentists are not permitted to disclose their negotiated insurance plan fee schedules, and they can vary in pricing from what one practice is able to negotiate to another. Larger practices with multiple doctors or locations are often able to negotiate higher fees for themselves due to their scale. So, you could end up paying a lot more than with a solo-practitioner.
Here’s how it works:
- Fee Schedule Negotiation: Insurance companies send fee schedules to dental practices, which the dentists may accept to become an in-network provider. Sometimes, the insurance companies will accept higher fees on certain procedures if the dental provider asks because the insurance company wants more in-network providers offering that procedure in the area.
- Periodic Adjustments: Over time, the insurance plan may raise or lower the amount it reimburses for specific procedures. Also, dental care providers will try to renegotiate their fees as their expenses increase.
- Balancing Affordability & Specialty Care: At Kelner Periodontics, we keep our fees for patients with no insurance close to our insurance-negotiated fee schedules so that even specialized procedures—such as gum grafts, bone grafts, or implant surgery—are accessible and reasonably priced for all patients. When we do need to raise our fees, we set them around the lowest quartile (25th percentile) in our area to ensure we remain both affordable and capable of delivering top-tier periodontal care.
Kelner Periodontics Will Help You Navigate Your Insurance Benefits
Navigating the ins and outs of dental insurance can be daunting, but it doesn’t have to be. By understanding the key differences between dental and medical insurance, timing procedures wisely, and obtaining a predetermination for major treatments, you can maximize the value of your coverage. Remember, seeing a specialist like a periodontist does not necessarily mean higher costs.
At Kelner Periodontics in Clark, NJ, we’re committed to ensuring our patients receive high-quality periodontal care. We verify your coverage, assist with insurance claims, and offer transparency at every step—from consultation to final procedure. We also encourage you to coordinate care among any other specialists or general dentists so you don’t accidentally exceed your annual maximum or miss important coverage deadlines.
Don’t let your benefits go to waste. If you have questions about your plan or want to schedule an appointment, contact us today at (732) 587-6740. We will answer all of your insurance-related questions, discuss financing options if needed, and work with you to maintain or restore your smile with minimal stress and hassle.