Guide for Understanding Dental Coverage in Alberta
In a province where general healthcare is public, dental coverage through private insurance and employer health benefits can be confusing to understand. We’re here to help. Dental Insurance is a great benefit, but should not be the guiding factor in your oral healthcare.
Dental health professionals diagnose and recommend treatment based on your individual oral health needs, not based on what your insurance covers. Recommended treatment is specific to your health needs. Our administrative team is your partner. We will help you to understand your coverage, how to ask your insurance for clarification, and assist you with options if your oral health goals and needs go beyond your coverage. Use this guide to gain an understanding of what your coverage is.
A general guide to dental insurance:
To begin we need to acknowledge that dental coverage is different from plan to plan and company to company, every person’s plan is different from the next, therefore this topic is difficult to explain in general terms. The purpose of this article is to assist you in understanding what your coverage is and what the terminology in your coverage explanation means. If you have questions about your plan please call your insurance company or ask us!
We recommend: Downloading your health insurance app or visiting their website and logging in. Find the area with the information on Your Coverage. Use that information alongside this article to understand your coverage, and have your coverage information with you when you call or come into our dental centre if you have any questions.
How does dental coverage work?
Private health and dental insurance provided through an employer or personally purchased by you will provide none, some, or full coverage for your dental treatment, with exceptions according to your specific plan. If you change your plan or insurance provider the coverage amount, frequency allotment, and exclusions may also change.
Terminology that is helpful to understand:
Coverage:
The dollar amount covered for treatment, or pooled total maximum covered for all covered treatments over a set amount of time. This is typically listed as a percentage of coverage up to a yearly maximum (total dollar amount they will cover that year).
Frequency:
How often your insurance will cover a specific treatment. Examples: 6 units of scaling every 12 months, 1 fluoride treatment per 12 months, 1 polish treatment every 6 months, 1 full exam every 12 months (your plan may have different frequency coverage than these examples).
Exclusions:
Items your benefits plan does not cover. While many plans cover a portion of every treatment item in an average 6-month or 12-month appointment, some treatments may have a limited frequency within your plan. While other treatments may be excluded or have age restrictions under your plan. For example, Cosmetic dentistry (ex. teeth whitening) is a common exclusion.
Fee guide:
Refers to your insurance company’s fee list. This list is not the same as your dental office’s fee list. Your insurance fee guide is what your insurance will pay out based on. If your company covers 80%, that means it will pay 80% of its own insurance fee guide, meaning it is not necessarily 80% of your dental office’s fee. Insurance fee guides are not always regularly updated.
Predetermination:
A predetermination of benefits is a submission to your insurance company to find out what is covered under your plan before beginning treatment. Your insurance company will review the recommended treatment and respond to inform the amount they will reimburse back you or the dental office under your plan.
Categories of dental treatment and how coverage applies
There are several categories of dental treatment, and most benefit plans have different coverage for each category. Below is an outline of the categories and information about how to understand your personal coverage associated with each category. Please note: your insurance company may have exclusions on some individual items or an entire category, this is a guide and the examples may not match what is covered by your plan.
Basic treatment:
Basic can also be broken down further into subcategories such as Diagnostic, Preventative, Endodontics, and Periodontics. For the purpose of understanding your coverage, these categories are grouped and referred to as Basic.
Examples of dental treatment and services in this category are scaling, polish, fluoride, fillings, x-rays, exams, root canals, custom night guards,
This is the main category of your dental coverage, it typically has a similar coverage level as your other health coverage categories (most commonly 70-100% coverage). Your personal coverage will have a listed percentage and a maximum dollar amount. For example, 80% up to $1500 maximum would mean your company will cover 80%* of the fee, up to a total of $1500 for the year. The yearly maximum will combine all of the basic subcategories, even if listed separately they will pool into the yearly maximum.
There are also limitations on the quantity covered per year of some items or frequency (time between the same procedure). We do our best to cater to any common coverage limitations for yearly appointments, however, we are not responsible for knowing your personal coverage as every plan is different.
*The percentage listed is according to your insurance company’s fee list and is typically somewhat different than your dental office fees and the Alberta fee guide.
Major treatment:
(May be combined with Basic yearly maximum or may have its own maximum)
Examples of Major Restorative Treatments are Crowns, Veneers, Bridges, Dentures, Implant Crowns and Implants.
Your plan may not cover all of these procedures, even if you have Major coverage. Major coverage is often 50% up to a yearly maximum, yours might be different.
Orthodontic treatment:
Orthodontic treatment (Invisalign®, braces, or Myobrace®) is a specific category of treatment. Your coverage will have it listed if it is included in your plan. Some plans only cover people 18 and under for orthodontic treatment, and most plans have a lifetime maximum (whereas the other categories are yearly) meaning there is a maximum coverage dollar amount for that individual on your plan for the lifetime of your plan.
Cosmetic treatment:
Cosmetic dentistry is any procedure with the primary goal of enhancing the visual appearance of a person’s smile. These are considered optional by most insurance plans. Including (but not limited to): teeth whitening, Botox, veneers, and some implants.
Have questions?
If anything about your coverage is unknown or a concern to you, it is best to contact your insurance company to ask for clarification or ask our office to send a predetermination to your insurance company. We are happy to work with you to add clarity to any of the information your insurance provides.
Important Note: Predeterminations can take 2 to 6 weeks to receive back and some insurance companies will only send predetermination directly to you as the patient, not to a dental office. It is important to call our office when you receive your predetermination, it will come to you via your insurance app, email, or mail depending on your insurance company.
Is dental included in our public health program?
In Alberta, dental coverage is not included in our standard public health program. However, there are several government programs available for individuals and families with disabilities, unique circumstances, or with low income, and the Government of Canada has a program for children of families with under $90,000 household income and who don’t otherwise have access to dental coverage. (Can we add seniors?)
What is direct billing?
Direct billing refers to when your dental office or another healthcare provider will send the claim for your treatment directly to your insurance company for you. If you have two insurance companies, we will send it to both! If there is a difference in the amount covered by the insurance company and the total, that amount is paid for by you, the patient. This is called the “patient portion”.
We can help
We want to eliminate any fears or uncertainty you may have about caring for your oral health. We are here to help! If the treatment you need is outside of your budget or your insurance does not cover it, we have financial partners and we will help you find the best solution for you! Don't let insurance or financing options stand in the way of your health. Call us today at 780-963-4626, we’re here for you. Health and patient care is our priority.
