Insurance

Being out-of-network means our office doesn't have a direct contract with your insurance provider, but we can still accept your insurance. For carriers we do have a direct contract with, in-network fees apply. When out-of-network, we use the base price for the service and apply the coverage percentages that correspond to your out-of-network benefits to calculate your payment. We accept major PPO insurances, but we are not contracted with Denti-Cal, Medi-Cal, or HMO plans.

The fundamental concept of dental insurance resembles that of other employer-provided insurances like Medical and Vision. Typically provided by employers, dental insurance involves monthly premiums and guidelines on preferred providers and benefits. A key distinction is that dental insurance has a yearly maximum for reimbursement, whereas medical insurance covers reimbursement after an individual reaches their out-of-pocket maximum.

Dental insurance functions similarly to medical insurance, but with a key distinction: the insurance provider covers up to a maximum allowable amount in a benefit period (typically a year), and the patient is responsible for any costs exceeding that limit. Understanding your plan's maximum allowable amount is crucial when considering more expensive treatments. Like medical co-insurance, dental PPO plans often cover services across categories: preventive, basic, and major. For instance, many PPO plans offer full coverage for preventive services, 80% coverage for basic services, and 50% coverage for major services. However, coverage specifics vary by plan, so it's essential to review your benefits to grasp your coverage. Patients are responsible for any costs not covered by insurance.

Dental insurance typically encompasses various dental services, including exams, cleanings (usually twice a year), basic procedures like fillings and crowns, as well as oral surgery and orthodontics. These services are categorized into preventive, basic, and major, each covered at a predetermined percentage, with the patient responsible for the remaining balance. Orthodontic coverage often has specific age restrictions, limitations on beneficiaries, and lifetime maximums rather than annual amounts.

A PPO, or "preferred provider organization," offers flexibility in choosing dentists without the need for a primary dentist. Referrals for specialists are not required, though staying within the network often yields cost savings. Contrarily, HMO/DHMO plans, which cover dental services at low or no copayments, necessitate selecting a primary dentist and restrict care to that provider unless referred to a specialist.

In most cases, PPO plans cover two exams and cleanings in a calendar year.

In many cases, dental implants are covered by insurance, but there are exceptions and rules to be aware of before proceeding with care. For example, a dental implant may not be covered if there's a "missing tooth clause" in your coverage, particularly if the tooth was missing prior. We can assist you in obtaining information regarding the specific rules and coverage applicable to you.

Typically, yes. However, orthodontic coverage often comes with specific age restrictions, limitations on beneficiaries, and a lifetime maximum rather than an annual amount. We can assist you in obtaining information about the specific rules and coverage applicable to your plan.