How much does my dental insurance pay for my Winter Park dental fillings?
How much does my dental insurance pay for my Winter Park dental fillings?
One question we get almost once a day – is how we calculate the patient's copay for a dental filling. Or said in reverse, how much is my dental insurance covering for my dental fillings? Unfortunately, it's not always straightforward. Certain procedures, like dental cleaning or extraction, are simple to estimate as cleaning is usually covered at 100%. Extractions are most commonly covered at 80%. This means that the patient’s copay is 20% of the insurance’s pre-determined fee.
If your Winter Park dentist has recommended dental fillings for you – read on to get an idea of how your treatment cost has been estimated.
What are the different types of dental fillings?
There are two broad types of dental fillings: Amalgam dental fillings – commonly called "metal" fillings or "silver" fillings are made of a mixture of metals, typically silver, copper, tin, mercury, and other metals. Thus, they are called "amalgam" to reference the mixed nature of the filling materials. Amalgam fillings have been used for over 150 years and are known for their strength and durability, and your local dentist will be well-trained in the procedures. They are also relatively inexpensive compared to other filling materials. However, some patients are concerned about the dark color of the filling as it can be visible depending on the area of the mouth and each individual's smile.
The second and more commonly prescribed type nowadays is Composite dental fillings – commonly called "white" fillings – which are made of a mixture of quartz or glass material inside a resin. They are a newer method of dental fillings, but your local dentist will also be well-trained in all modern composite filling techniques. They are offered in multiple colors and 'shades' to match the color of your natural teeth. Composite fillings bond directly to the tooth, which can help support the remaining tooth structure and help minimize the amount of 'natural' tooth removed from the dental restoration process. Composite fillings are less noticeable than amalgam fillings, which makes them preferred for almost all restorations in the mouth – but particularly for cosmetic dentistry on front teeth, as they are most visible. However, composite fillings are more expensive than amalgam fillings as the materials are more advanced and require additional skills, experience, and steps to complete.
How is my copay calculated with dental insurance?
The following description is intended for the most popular types of dental insurance we see in the Winter Park area. However, your specific insurance policy could vary both in pricing and specific rules.
For composite fillings (most common), we need to account for three things:
your deductible, which the insurance has you pay before any basic or major procedure
the percentage of coverage for the specific procedure (in this case, fillings)
any substitutions or "downgrades" your policy will make (in this case, downgrading white fillings to metal fillings)
For #1, the most common deductible is $50. So, any procedure this applies to will account for your $50 copay first. This does reset annually, so you are only paying it once across any office. Even if you were to visit your Winter Park dentist for a dental filling and then visit a root canal specialist later in the year – you wouldn't have to pay the $50 deductible again at the specialist visit.
For #2, the most common is 80% coverage on fillings. This means insurance will pay for 80% of their pre-determined fee. In the case of your Winter Park dentist, if they are in-network with the insurance, the insurance company sets this fee and typically factors in a discount for being a member. Your responsibility would be 20% of that fee.
Finally, for #3, most insurances have an "alternate benefit for white fillings" (which means they will pay for the medically acceptable, lower-cost fillings but have patient pay extra for the white fillings), then we need to look up how much your insurance will consider as the payment amount for a metal filling on the same tooth.
In regards to white vs metal fillings, it is a choice for you if you would prefer to have metal amalgam fillings, and it will lead to a lower copay for you. However, most patients prefer white fillings as they are virtually invisible when completed and typically have some clinical advantages with bonding. To streamline most treatment plans, we assume patients prefer a white filling unless otherwise clinically specified by the doctor. If you want to switch to all metal fillings, please let us know!
To help "make it real," here's a detailed example with the math to show you how it gets calculated. Let’s assume a patient needs two dental fillings. One for tooth #3 and another for tooth #31. When a patient has 80% coverage for fillings, the numbers below certainly don’t seem like it. Let’s see how the estimate is calculated.
Tooth #: # 3; #31
Deductible? Y; Y
Substitution? Y; Y
Procedure Code: D2391; D2391
Procedure Description: One surface, composite (white) filling;
One surface, composite (white) filling
Total fee (set by insurance): $137.00; $137.00
Insurance Pays: $28.00; $68.00
Patient Pays: $109.00; $69.00
For tooth #3, the diagnosis is a D2391 - 1 surface, composite (white) filling. The insurance contracted fee for D2391 is $137. However, because of the "downgrade," they will consider it as D2140, which is a one-surface amalgam filling. The fee for D2140 is $85.
We first calculate how much insurance will pay for this procedure. The total fee is $137, but insurance sees it as $85. The $85 doesn't apply until we take out the deductible (one time per year), so they are considering ($85-$50) = $35. Of the $35, they will cover 80%. So we then multiply as ($35 x 80%) = $28. Insurance will cover $28 on this first filing. As a result, to calculate your patient copay, we take the total fee of $137 and subtract their $28. ($137 - $28) = $109 for the first filling. This is your total copay, which includes the deductible, the additional fee for the white filling, and the 20% copay you have for any fillings.
We can do a second example, and because your deductible has already been paid, it will be simpler and cheaper. Because the deductible will only apply once a year, if we look at tooth #31, it is also D2391 - therefore, the fee is also $137. Because insurance will consider it at $85 metal filling, they then cover 80% of that. ($85 x 80%) = $68. Therefore, the patient copay would be ($137 - $68) = $69.
What if my insurance policy covers all white fillings?
While we do see that most insurances don't cover white fillings on posterior teeth (like molar teeth), there are certainly great insurance policies that cover the cost of white fillings. In this case, the insurance estimate is easy to calculate. With the procedure fee of $137 and 80% coverage, then insurance will cover ($137 x 80%) = $109.60, and the patient copay will only be $27.40. Rest assured that, with all in-network insurances, anytime your insurance pays more than estimated, we will process an appropriate refund in your form of payment!
Email Us!