Millbrae Dental Care
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Understanding Dental Insurance & Dental Plans

An article written with Dr. Sherry Tsai

percent symbol showing how to calculate insurance copays out of pocket
No doubt about it, understanding and making sense of dental insurance can be confusing and time-consuming. Understanding the difference between a PPO (Preferred Provider Organization) and an HMO (Health Maintenance Organization), terminology such as capitation, Flex Spending (Flexible Spending Accounts or FSA), reimbursements, copays, and limitations are enough to intimidate anyone. However, taking a step-by-step approach, dental patients can learn the difference between the various types of dental insurance plans, as well as which dental plan is best suited for yourself and your family. Dr. Tsai knows that insurance companies make it difficult to understand policies and benefits, but she and her team make it easy for you by being proactive with your insurance. This guide is to help you better understand your insurance plan. Though your specific details will differ, it allows you to explore and understand the limitations of dental insurance.

Because of rising health-care costs and dental costs, a shaky economy and efforts to save money, more employers are reducing choices and benefits for employees, especially in dental insurance. Patients need to take a proactive stance when it comes to researching the best type of dental insurance plan to protect them and their family. Dr. Tsai never lets insurance benefits interfere with proper and proactive dental health – your health. Though it's your dental insurance, Dr. Tsai has team members dedicated to helping you understand the details of each dental insurance plan. If you ever have questions about your dental coverage, please give her team a call.

What you should know about dental insurance coverage


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Most dental insurance plans offer basic coverage called preventive dental care, including regular checkups, cleaning, prevention of gum and tooth diseases; maintenance including fillings, extractions; and some major treatments. However, many plans don't cover dental surgery, dentures, or orthodontics. Why don't they cover everything? Basically, it comes down to cost. Dental insurance plans, and employers, don't offer full protection against all scenarios, but they are rather designed to offer monetary benefits that are designed to help you offset your costs. Since employers pay the bulk of the monthly premiums, they alter plans to save themselves money, thereby passing the cost on to you. Actually, most dental plans only cover a portion of total costs of dental treatments.

Despite rising healthcare costs and standard of living, most insurance companies have not increased basic benefits in over two decades. This explains why most patients continue to pay what are known as copays. Dental insurance plans also include a deductible, which is defined as a pre-agreed-upon amount of money that a patient must pay before insurance companies pay for treatments and services. Deductibles are also commonly known as out-of-pocket expenses. Patients must consider deductibles and copays, out-of-pocket expenses, as well as money paid for treatments or procedures that aren't covered under the dental insurance policy to dental providers.

Common dental insurance limitations


dental limitations
Patients should also be aware of limitations of various services found in dental plans. For example, many insurance companies require patients to wait for a certain amount of time between the start of your plan (even though you are paying a monthly premium) and the time you obtain major dental care, such as crowns, bridges, etc. This is called a Waiting Period, and it allows the dental insurance companies to collect their money up front. Another common example is that some dental insurance companies place a limit on how many fillings, x-rays, extractions, and cleaning are allowed on a yearly basis. Be sure to ask your HR department or insurance broker about these limitations. You can also ask Dr. Tsai’s team to look up your benefits for you. She and her team want you to get all your entitled benefits.

Other terms commonly found in dental insurance policies include capitation, reimbursement, and Flex Spending. Many dental providers, especially those who belong to HMO organizations, offer capitation plans. Such plans pay a dentist a set amount each month whether or not you come into their office. They also pay a predetermined amount of money for specific dental procedures: no more and no less, regardless of how much time, effort, visits or procedures a specific patient may require. These plans tend to yield lower-quality dentistry as the doctor's incentive is to not see you or to perform the minimum preventative treatment possible. As a result, high-quality dentists like Dr. Tsai and her team choose not to work with HMO plans.

Dental insurance plan reimbursement


doller sign symbolizing cost of dental implants
Reimbursement is a predetermined amount of money the dental provider may receive for services rendered. Some dental insurance plans require patients to pay for services rendered and then submit an insurance claim form to the dental insurance company for reimbursement, or repayment. These are typically plans that employers set up to “self-insure” their employees. You are allowed to see any provider you choose, and you pay the provider for the dental services; your employer reimburses you up to the set limit. The nice thing about these plans is the flexibility it allows – you can choose any provider you want. They also typically have fewer exceptions and limitations on procedures.

A dental Flex Spending Account is a medical or health expense account set up through an individual's bank, broker or employer. This health-related expense account may be used to meet unexpected or planned-for dental expenses. In most cases, a set amount from your paycheck is deposited into your flex account during each pay period. Similar to health savings accounts, some money placed in flex spending accounts are not subject to Social Security or income taxes. Most plans limit the amount of money that may be deposited into such accounts on an annual basis to $2,000-$3,000. However, individuals should know that unused money left in a flex spending account at the end of the year is forfeited, so it's essential to use that money!

Dental PPO vs. Dental HMO Insurance- Which is Better?


box of chocolates symbolizing that there are many choices of dental insurance
Dr. Tsai encourages patients to carefully read through dental insurance policies to determine maximum benefits allowed for individuals or families on an annual basis. Patients should also be aware of and understand exactly what's covered and what's not under basic dental insurance plans coverage.


Currently, there are two types of plans commonly used::

» PPO - stands for Preferred Provider Organization. This type of organization is made up of health insurance providers who have formed a network of dental professionals to offer services to consumers. Dentists who belong to a PPO offer lower fees to patients. However, individuals belonging to a PPO must choose a dental provider from within the network of dentists offered by the health insurance company in order to save on costs. Patients can choose dentists outside of the provider's network, but this may change their copays. Fortunately, Dr. Tsai is one of the very few highly trained dentists who have remains in network for many of the more common insurance plans.

» HMO - stands for Health Maintenance Organization. Patients enrolled in HMO plans are required to choose a dental professional from within the network. Patients who use dentists outside of the network are required to pay that dentist's bill in full. Patients should know that PPO providers are paid on a per-service basis, while dentists belonging to HMOs are only paid a set fee for services, often resulting in lower quality dentistry and lab work. PPO providers are therefore able to provide much higher quality dental care and treatments. Dr. Tsai works with all major PPO plans including unions, individual plans and groups, and employer plans.

Millbrae Dental Care Works With Most PPO Dental Plans


Dr. Tsai and her team are available to help patients wade through all the details of their plans, from copays to deductibles and limitations. Her team has worked with almost every dental insurance plan in the Bay Area and can help you navigate the details while maintaining that beautiful smile of yours. Dr. Tsai is a progressive and proactive doctor who focuses on the latest methods, techniques, and tools dentistry has to offer. She is dedicated to preserving your natural tooth structure, taking care of all your dental needs in a comfortable, conservative, and informative environment.


Have questions about your dental insurance plans? We can help. email or call us: (650)-583-5880
We'd love to hear from you.




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Dr. Sherry Tsai works with most dental insurance plans in the Millbrae, San Bruno, Burlingame, San Mateo and the Bay Area