The following list of terms may help you better understand your insurance policy.  However, it is not an exhaustive list (and may be applied differently).

1. Premium – Your premium is your monthly insurance policy payments.  

2. Copay – Your copay (or “copayment”) is the set amount you pay your doctor for your appointment.  For example, if you pay $50 each time you visit your doctor, that is often your copay.  This varies depending on your policy and what your doctor charges.  Your copay is the amount due at the time of service for policy benefits.

3. Deductible – Your deductible is the amount you must pay each year for eligible dental and medical services or prescriptions before your insurance begins to share in the cost of covered services.  Your deductible is specific to your insurance plan.  You are responsible to know what your deductible is before committing to any treatment.  For example, if you have a $2,000 yearly deductible, you’ll need to pay the first $2,000 of your total eligible medical costs before your plan begins to pay. (Note: Copays typically don’t count toward your deductible.)

4. Coinsurance – Your coinsurance is a portion of the medical cost you pay after your deductible has been met.  For example, if your coinsurance is 20%, you pay 20% of the cost of your covered medical bills after your deductible, and your insurance will pay the remaining 80%.  If you meet your yearly deductible in June, and need a covered service in July, then it will be covered by coinsurance.  For example, if your covered charges for an eligible service is $2,000, and your coinsurance is 20%, you will need to pay $400 (20% of $2,000), and your insurance will pay the remaining $1,600 (80% of $2,000).  The higher your coinsurance percentage, the higher your share of the cost will be.

5. Out-of-Pocket Maximum – Out-of-pocket maximum is the maximum amount you are responsible for paying in a year that your insurance won’t cover.  Typically, this amount includes copays, deductibles, and coinsurance.  Once you reach your yearly out-of-pocket maximum, your insurance will pay your covered medical and prescription costs for the remaining year. 

6. Yearly maximum – Most dental insurance plans set a yearly maximum limit of coverage (that is, the most they’ll cover you for the year.)  This amount may change without them notifying you.  So review your policy before committing to treatment.

7. Eligibility – This determines if you (and the treatment requested) are covered under the specific insurance policy.

8. Exclusion – Your insurance plan may exclude coverage for certain dental and medical treatments.  This does not mean those treatments are not important or necessary.  It simply means the insurance plan does not cover it.

9. Policy Limits – Most dental insurance plans set annual coverage limits and often pay only a portion of the treatment cost.

10. In-network – In-network refers to health care providers that are part of an insurance plan’s network of providers.  Some patients mistakenly think “accepting” an insurance with being an in-network provider.  Your insurance may possibly still be accepted by us even if we’re not in-network with them.

Many dental insurance policies with out-of-network (OON) benefits will cover most or all of the treatment cost at Brushwell Dental.

We DO NOT work with the following insurance plans:

• Denti-Cal
• HMO plans

If you have the above dental care coverage—but limited to no financial resources—there is still help available.  Visit the listings of MHLA Dental to view your options.  You can also call (213) 351-1270 to speak with a representative of the LA County Department of Public Health.

Here is a partial list of PPO dental insurance plans we DO accept (and are NOT in-network with).  This means you can STILL use your benefits at our office.

Many people think their insurance pays 90-100% for every dental procedure.  Truth is, most dental insurance plans only pay between 50-80% of the average total fee that is negotiated between the employer and the insurance company.  Dentists are NOT involved in that contract that sets the fee for the insurance policy.  Thus, we do not know what your benefits are until we submit for a pre-authorization.  (Even then, there are no guarantees for benefits.)   At times, you will find that our fees are different from what your policy assumes it may be. 

Some insurance plans pay more, others pay less.  The amount paid is often determined by how much you pay for coverage or the type of insurance plan your employer offers.

We DO NOT know what your insurance policy helps with until we submit for pre-authorization.  We commonly submit a pre-authorization after our doctor’s examination if further treatment is necessary.  You are responsible for the fees that are not covered by your dental insurance.

No, dental offices do not determine insurance benefits.  Only insurance companies do.  We are not responsible for how your insurance company deals with its claims or for what benefits they pay on a claim.  We can only help in estimating your portion of the treatment cost.

Have you ever noticed your insurance company reimbursing you (or your dentist) at a lower amount than your dentist’s quoted fee?  And your insurance company replies that the reason they reimbursed at a lower amount is because your dentist’s fee exceeded their UCR fee (that’s short for Usual, Customary, and Reasonable fee).

This type of reply can give the false impression that any fee above their lowered reimbursement is unusual and unreasonable—that the fee exceeds what most dentists in the area charge for that treatment.  Unfortunately, this is simply not true.

Here’s how insurance companies determine their UCR fee.  They collect fee data from the claims they processed.  They then take this data and arbitrarily choose an allowable UCR fee.  And often, this data can be three- to five-years old, and their UCR fees are then further reduced so they can earn a 20-30% net profit.

Their lowered reimbursements may give the impression that your dentist is overcharging, when in reality, they’re actually underpaying.  As a rule of thumb, the lower the insurance premium, the lower the UCR fee; hence, the lower your reimbursement.

Here’s the unfortunate truth: insurance companies are in the business of making a profit, which means, they would rather not pay what they don’t have to.  They may consider a treatment unnecessary.  And when that happens, we appeal by sending them additional evidence that treatment is necessary, such as diagnostic radiographs and intra-oral photographs.   However, submitting such documentation may not be enough in some instances.  Many patients may not understand that insurance companies always have the final say when it comes to deciding how much to help the patient.  Regardless, we will do our part to help advocate for our patients.

You must take into account your deductible and copay (both of which, you pay).

Here’s an example.  Imagine you were charged for a $300 service.  Assuming the insurance company allows $300 as its usual, customary, and reasonable (UCR) fee, you can figure out what benefits will be paid.  First, your deductible (paid by you), on average $50, is subtracted from $300—leaving $250.  The plan then pays 80% for this particular procedure.  The insurance company will then pay 80% of $250, that is, $200.  Out of a $300 fee, they will pay an estimated $200, leaving a remaining portion of $100 (paid by you).  On the other hand, if the UCR fee is less than $300 or your plan pays only at 50% instead of 80%, then your insurance benefits will be much lower.

Brushwell Dental is an “out-of-network” (non-restricted) provider for all dental insurances.  We are a “fee-for-service” dental office.  Our dental procedure fees are aligned with our doctors’ clinical expertise and quality of results.  Our procedure fees will not be aligned with any dental insurance fee schedule.  We also do not participate in any Denti-Cal or HMO dental plans.

If you currently have a dental insurance plan with benefits, then we encourage you to contact your dental insurance company to check if your dental insurance plan has any “out-of-network” dental benefits.  Nearly all PPO plans have “out-of-network” benefits.  If you have any questions, please contact us at (626) 288-8940.

• Subscriber’s name
• Address and phone number
• Birth date
• Social security number and/or Insurance ID number
• Employer name
• Employer address and phone number
• Group number
• Insurance company name and phone number