Dental insurance 101

Provider networks

Each dental plan has a provider network. This is a group of dentists that work closely with a dental insurer to provide services and treatment at a set fee, usually at a reduced rate. Most BlueDental plans allow you to see any dental provider for services, but seeing a dentist in our provider network will help ensure you receive cost-effective, high-quality care.

There are several benefits to seeking care from an in-network dentist or specialist:

• Your out-of-pocket costs are lower than if you get care from an out-of-network dentist because our local dental network team negotiates significant discounts with dentists in our network.

• In-network dentists file claims for you. An out-of-network dentist is not required to file your claim, so you may need to file a claim yourself to be reimbursed.

• Out-of-network dentists usually require you to pay the full cost of a service before rendering the service.

Our local team of network managers employs a thorough credentialing process that ensures that our networks include only dentists who meet our high standards of quality. It’s easy to find a dentist in our network.

Types of dental plans

Preferred provider organizations (PPO) and prepaid plans are two of the most common types of dental insurance. Florida Blue also offers many health plan options, including Medicare Advantage, that include dental coverage.

PPO plans

BlueDental Choice^SM, Copayment, and Choice Plus are PPO plans. If you’re a BlueDental PPO member, you have access to a large and growing dental network in Florida and nationwide. You can choose to get care from any dentist, in or out of network, but you’ll realize greater savings, including low or no out-of-pocket costs for preventive services, if you choose a dentist in our network. The networks for each plan may include different providers, so be sure you select your plan when searching for a provider using the find a dentist tool.

Prepaid plans

Our BlueDental Care prepaid plan has a smaller network and provides no out-of-network benefits. You will also need to choose a dentist from the Care network when you enroll in your plan. While prepaid plans usually have lower premiums than PPO plans, they offer lower reimbursement for services and do not cover services or treatment provided by out-of-network dentists or specialists or services received out of state.

Florida Blue health plans

Some Florida Blue health plans, including most Florida Blue Medicare plans, include dental benefits. Whether a Florida Blue Medicare Advantage plan member has a PPO or HMO plan, ALL dental benefits embedded in these plans are PPO benefits.

Types of dental services

Your dental plan provides you with valuable financial protection against possible risk. Dental services generally fall into three categories:

Preventive: Most dental plans cover preventive care at 100%. This includes exams, cleanings, and X-rays. Some plans cover preventive services for children, such as sealants, at no additional cost.

Basic services: Treatment for gum disease, tooth extractions, fillings, and root canals are considered basic services. Most dental plans will pay most of the cost of these services, while you’ll be responsible for a portion of the cost.

Major procedures: Crowns, bridges, inlays, and dentures involve higher out-of-pocket costs than basic procedures.

Some plans may include coverage for orthodontics (such as braces) or dental implants. For plans without orthodontia coverage, discounts are available when you choose a provider in our orthodontic and cosmetic discount networks.

All BlueDental PPO and Florida Blue Medicare plans also cover virtual dental visits if you experience a dental emergency.

Dental services may be categorized differently based on your plan, so check your plan’s policy before you receive services.

What you pay for dental insurance

Like most types of insurance, you must make regular payments to get and keep your coverage. This is called a premium. There may also be cost-sharing payments, or “out-of-pocket expenses,” that you may need to pay for certain treatments. Unlike premiums, out-of-pocket expenses are tied to the services you receive, and they help keep premiums more affordable for everyone.

Cost-sharing or out-of-pocket expenses include:

• Deductibles: The fixed amount you may need to pay for covered services before your insurance plan begins paying.

• Copayments: The fixed amount you pay at each visit to the dentist. A dentist in our network will charge you for a covered service based on a set rate listed in a fee schedule. Copayments don’t apply to your deductible.

• Coinsurance: Coinsurance is a fixed percentage of a treatment cost you share with your dental plan. You must first meet your deductible and not exceed your plan’s annual maximum for the year.

All plans require premium payments and many have a deductible. All plans also require either a copayment or coinsurance for some services.

Out-of-pocket costs are often capped for pediatric dental coverage. This is called an out-of-pocket maximum and is the total amount you’ll pay for your child’s dental care during a calendar year. Coverage for adults usually doesn’t have an out-of-pocket maximum.

Other important factors

Waiting periods

Some dental plans require you to wait for a period of time before you can receive certain services. Review your policy to see if any waiting periods apply.

Annual maximum benefits

PPO dental plans typically have a yearly limit on what the plan will pay for services. If you exceed your plan’s annual maximum, you may be responsible for paying costs over the maximum. If your plan includes our Maximum Rollover benefit, you may be able to use funds that have rolled over from a previous calendar year to offset the cost of services that exceed your plan’s annual maximum.

A better standard of care

BlueDental plans offer you flexible dental plan options that will help you stay healthy and within budget. Our large and growing network allows you to enjoy excellent care and in-network savings throughout Florida and nationwide. Plus, our dental and medical plans work together to promote better health. Check out our plan comparison page or talk to an agent or one of our helpful representatives at a Florida Blue Center near you.

Stay on top of your dental—and overall—health

Poor oral health can also worsen certain medical conditions. The bacteria that cause gum disease can enter your bloodstream through gum tissue and affect other parts of your body.

Regular visits to the dentist go beyond an examination of teeth and gums. Your dentist looks at your head, neck, and jaw and thoroughly examines your mouth for warning signs of disease elsewhere in your body.

Leave the dentist feeling better

Dental issues can interfere with eating, speaking, daily activities, and even your self-esteem. Regular visits can prevent tooth loss, bad breath, sensitive teeth, and feelings of embarrassment. Regular cleanings are the best way to remove tartar, which can lead to bigger problems if not removed.

What happens during a preventive visit?

Your preventive visit typically includes an evaluation, X-ray, and a cleaning.

Evaluation

The dental staff will ask you about medical conditions, medications, and your lifestyle to evaluate the effect of your dental health on your whole body. Then, the hygienist and dentist will look for cavities and signs of decay and bone or gum disease. Your dentist will check the health of your mouth, neck, and face to screen for oral cancer.

If any issues are found during your exam, your dentist will recommend a treatment plan (including all options, if possible) to fix the problem and stop it from worsening. If better habits will help improve your dental health, your dentist or hygienist will teach you how to brush and floss effectively. If needed, your dentist may talk to you about lifestyle changes, such as quitting smoking or improving your diet. If you’d like to improve the appearance of your smile, your dentist may have some recommendations.

X-rays

Your dentist will take X-rays of your teeth, gums, underlying bone, and jaws to check their structure and health.

Cleaning

Professional cleanings are the best way to remove plaque and tartar, which can lead to bigger problems if they aren’t removed. Once plaque hardens into tartar, only a dentist or dental hygienist can remove it. Typically, after plaque and tartar are removed from your teeth, the hygienist will polish them.

Talk to your dentist and staff if you’re nervous about the exam or have any other concerns. They have experience with anxious patients and can help you feel more comfortable.

Scheduling preventive care

For most people, an exam and cleaning are recommended every six months. If you have a medical condition or issues with your teeth and/or gums, your dentist may recommend treatment more frequently. Our Oral Health for Overall Health^SM program provides four preventive visits per year at no additional cost for anyone with an eligible medical condition.

Take advantage of preventive services

Your BlueDental plan covers twice-yearly exams and cleanings at little to no cost when you see a dentist in our network.

Don’t skip a dental checkup because of cost, time, or anxiety. In the long run, missing visits will likely cost you more. If you haven’t seen your dentist in the last six months, make an appointment today. If you don’t have one, you can find a dentist near you.

What is the difference between a pre-treatment estimate and a prior authorization?

While a pre-treatment estimate is just an estimate of the cost of services your dentist recommends, depending on your plan, some dental services may require prior authorization (or approval). Your dentist may need to submit additional documentation, including chart notes, X-rays, or photos, to determine if the recommended treatment is medically necessary or meets your plan’s criteria for coverage. Prior authorizations are typically required for major services such as periodontal treatment, oral surgery, endodontic treatment, orthodontics, crowns, bridges, dentures, or partials.

Review your plan’s coverage

It’s a good idea to review the coverage in your policy before scheduling treatment, especially complex procedures. You have 24/7 access to your dental benefits information in one secure place online at your member account. If you need additional help, call the number on the back of your ID card, and we’ll be happy to answer any of your questions.

How do I submit a claim for out-of-network care?

You will need to complete a separate claim form for each covered member who received services from each provider. You must file your claim within one year after the last day you received services; claims filed after one year aren’t eligible for payment.

You’ll need to include a signed letter with your claim that includes:

• A daytime phone number

• Your BlueDental member ID number (the number is printed on your member card)

• Information about other dental coverage you may have

Enclose an itemized statement of services received from your dentist in English or a statement in a foreign language with an English translation on the provider’s stationery. The provider statement must include all of the following:

• The dentist’s name, address, and phone number

• The patient’s name

• The date(s) each service was performed

• The charge for each service in U.S. currency

• A description of each service using the correct Current Dental Terminology code (CDT)

• Where you received the service

A claim without a provider statement will be denied. Statements that you prepare, cash register receipts, receipt of payment notices, or balance due notices will not be accepted.

Mail your claim to Florida Combined Life, P.O. Box 69436, Harrisburg, PA 17106-9436.

Explanation of benefits

Each time you visit the dentist, we will send you an explanation of benefits (EOB) statement that explains how we processed your claim based on the services performed. An EOB is not a bill.

The EOB includes:

• The date you received the service

• The amount billed

• The amount covered

• The amount we paid

• Any balance you’re responsible for paying the provider

• How much has been credited toward any required deductible or annual maximum

Each time you receive an EOB, review it closely and compare it to the receipt or statement from your dentist. You can choose paperless EOBs by selecting the option in your member account. Learn how to read your EOB.

Timeframe for claim determination

If we receive all the information we need to process your claim, we’ll send you an EOB within 20 days of receiving your claim for a claim submitted electronically or 40 days for a mailed paper claim. However, if we need more information or cannot make a decision due to circumstances beyond our control, we may extend our response time by an additional 15 days. We’ll let you know within 30 days why we’re extending our response time and when you can expect our decision. If we need more information, you’ll have at least 45 days to provide it.

Denials

If any services on your claim are denied, the EOB will explain why. If you disagree with the decision to deny your claim or request for coverage, please contact us. You may request an appeal if you’re unsatisfied with the explanation provided.

There are certain cases when a claim for dental services may be denied even after you’ve received the service and the claim has been paid. Some examples include:

• Using an expired Florida Blue membership card to get services. If the provider doesn’t verify eligibility over the phone or electronically, the service may be denied when the claim is filed.

• Not getting preauthorization for a service that requires it.

• Getting a service that’s not a benefit of your plan.

The best ways to prevent denials are to pay your premiums on time, talk to your providers about what’s covered before you get services, and learn about your BlueDental plan benefits.

Retroactive claim denials

Florida Blue doesn’t request refunds for claims paid when a member’s termination date is adjusted retroactively unless the enrollee ends their BlueDental plan and enrolls in another insurer’s dental plan. In all other circumstances, once a termination date is added to a member’s record, claims are processed or denied based on that date. However, if a member ends their BlueDental plan and enrolls in another insurer’s plan, Florida Blue will request a refund from the provider for any claims paid after the retroactive termination date. The provider is responsible for refunding the member for payment of any cost shares. Providers are responsible for billing the new insurance company for any covered services that you receive and were paid for after the retroactive enrollment date. Florida Blue instructs providers to collect only the copayment or coinsurance for the covered service to reflect the member’s cost-sharing obligation for their plan. Such an adjustment may result in the member making additional payments to the provider. Florida Blue advises providers that any refund or credit for any excess cost sharing must be provided (or begin to be provided in the case of a credit) within 45 calendar days of the date of discovery of the excess cost sharing. In the case of a premium paid for or on behalf of the enrollee, any refund or credit for any premium paid for or on behalf of the enrollee will be provided (or begin to be provided in the case of a credit) by Florida Blue within 45 calendar days of the date of discovery of the excess premium paid.

Prior authorization

Prior authorization is an approval process to ensure that certain treatments, procedures, or devices meet payment determination criteria before the service is rendered. If you’re under the care of a Florida Blue participating dental or in-network provider, the provider will get your approval.

Prior authorization for nonurgent dental care

If your request for prior authorization isn’t urgent, Florida Blue will respond within a reasonable time appropriate to your case’s clinical circumstances. We’ll typically respond within 15 business days of receiving your request. We may extend our response time an additional 15 business days if we can’t respond within the first 15 business days or due to circumstances beyond our control. If this happens, we’ll let you know before the end of the first 15 business days. We’ll tell you why we’re extending our response time and when we expect to make a decision. We’ll let you know if we need more information and give you at least 45 business days to provide it.

Prior authorization for urgent dental care

Your care is urgent if the time periods that apply to prior authorization for nonurgent care:

• Could seriously risk your life or health or your ability to regain maximum function.

• In your doctor’s or dentist’s opinion, a delay would subject you to severe pain that can’t be adequately managed without the care that’s the subject of the request for prior authorization.

Florida Blue will respond to your request for prior authorization of urgent care within 24 hours of receiving the information required.

If we don’t receive enough information to help us make a decision about your request, we’ll let you know within 24 hours. We’ll let you know what we need and give you at least 48 hours to provide it.

Payment of claims during a grace period

If you are enrolled in an individual BlueDental Choice^SM or Copayment Q or QF plan and do not pay your premium on or before the due date, you are entitled to a grace period.

• For individual Affordable Care Act (ACA) plans, we allow a three-month grace period to pay each premium after the initial premium.

• The grace period for non-ACA individual and group plans is 31 days.

• You will have a three-month grace period if you purchase a BlueDental plan directly from Florida Blue (off-marketplace plans) or on-marketplace but do not receive a subsidy. To keep your coverage, you’ll need to pay your premium before the end of the three months. If you don’t, your policy will be canceled. You’ll lose coverage retroactive to the last paid-through date and will be responsible for any claims for services you received after that date.

• If you purchase your plan on-marketplace and receive a subsidy to help pay for your coverage, claims will be paid during the first month of the grace period for all eligible dental services rendered. During the second and third months of the grace period, claims may pend and be denied if past due premiums are not received.

• If the premium is not received prior to the end of the grace period, the policy will be canceled.

If you have questions about filing claims, call us at 888-223-4892, Monday - Friday, 8 a.m. - 8 p.m. ET.

Actual charge

The actual charge is the amount a provider bills a patient for services or supplies.

Annual maximum

Your dental plan’s annual maximum is the maximum dollar amount your plan will pay toward the cost of dental treatment or services during a calendar or plan year (typically a 12-month period). The annual maximum applies only to the portion your plan pays for services you receive. Out-of-pocket costs such as deductibles or copayments do not count toward your annual maximum. Once the annual maximum is reached, any additional dental services you receive will not be covered until the next plan year.

BlueDental Loyalty

If you’re over 18 and have an individual BlueDental Choice^SM or Copayment plan (a plan you purchased yourself and not through an employer), our BlueDental Loyalty program provides you with extra services after reaching membership milestones, beginning at just six months.

Calendar year

A calendar year is the 12-month period that begins on January 1 and ends on December 31. The 12-month period your dental plan covers is called a plan year.

COBRA

The Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) is a federal law that allows covered employees and their eligible dependents to pay for continued dental plan benefits if their plan ends because of a qualifying event, such as leaving a job or getting a divorce.

Coinsurance

Coinsurance describes the sharing of expenses for covered dental benefits between the insurance company and the insured. After an insured member’s deductible is met, the insurance company will pay a percentage of the allowance (listed in the policy schedule). The insured member is responsible for the remaining percentage of the allowance (if any), and for all non-covered services and charges that exceed the benefit maximum.

Let’s say your plan pays 80% coinsurance for a dental service. If the service costs $150, you pay 20% ($30), and your dental plan pays 80% ($120) after your deductible has been met.

If insured members get care from an out-of-network dentist, they are responsible for paying the difference between the insurance company’s allowance for the services provided and what the dentist charges for the service, if that applies.

Coordination of benefits

You may have another dental plan that provides the same or similar benefits as your BlueDental plan. If you have another dental plan, we’ll work with that plan to determine which plan is the primary payer and which is secondary. Other coverage includes group-sponsored insurance, non-group-sponsored insurance, other group benefit plans, Medicare or other government benefits, and dental benefits that may be included in your automobile insurance.

If you have more than one dental plan, please review the Coordination of Dental Benefits section in your dental policy documents.

Copayment

A copayment is the fixed amount you pay for a service or treatment rendered by your dentist in addition to a deductible, if applicable. A dentist in our network will charge you for a covered service based on a set fee listed in a fee schedule. Copayments do not apply to your deductible.

Deductible

A deductible is the set dollar amount you must pay for covered services each calendar year before reimbursement for dental benefits begins. For example, if you have a $50 deductible for services and the charge for a treatment you receive is $120, you would pay $50 to meet the deductible, and your plan will cover the remaining $70 (if you have not exceeded your plan’s annual maximum for the year).

Eligible charge

An eligible charge is the portion of a charge made for covered services that an in-network dentist renders. The dentist is reimbursed for the services provided in the agreed-upon amount between the insurance company and the dentist. For example, suppose an in-network dentist charges $100 for a treatment (the actual charge), but the insurance company agrees to a $75 eligible charge for the treatment. In that case, the dentist will bill you $75, you will pay a portion of it (your copayment or coinsurance), and your plan covers the rest. If an out-of-network dentist charges more than the allowed amount, you may have to pay the difference.

Explanation of Benefits (EOB)

A statement that explains how we processed a claim based on the charges for any services performed, the allowed amount for those services, the amount you may owe, and other adjustments to the charges for the services provided, if applicable. Learn how to read your EOB.

Florida Blue member account

A secure area on Florida Blue’s website that lets you manage both your Florida Blue medical and BlueDental plan benefits. Your Florida Blue member account gives you access to information about your plan and claims, forms, and other tools and information.

General dentist

A general dentist is a participating general dentist within a plan’s network whom you have selected to handle your dental care.

Health care reform

One of the primary goals of the comprehensive health care reform law enacted in March 2010 (sometimes known as the Affordable Care Act, ACA, or PPACA) was to make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level. The ACA also considers dental coverage an essential health benefit (EHB) for children under 18, so it must be available as part of a health plan or as a stand-alone plan. Individuals and small group employers can purchase ACA-compliant BlueDental Choice^SM and Copayment QF/Q plans.

Individual plans

An individual dental plan is coverage you buy for yourself and/or your family directly from an insurance company or through the Health Insurance Marketplace when you don’t have access to group insurance coverage through an employer or prefer to obtain coverage your employer does not offer.

Maximum allowance

The maximum allowance is the maximum amount your plan will pay for a covered treatment or service. If your dentist charges more than your plan’s allowed amount, you may have to pay the difference.

Maximum Rollover

Maximum Rollover is a benefit included in many BlueDental PPO plans that allows you to save unused benefit dollars in a given year for use in future years. You can plan and schedule major services in advance or have additional benefit dollars available to use if you need an unexpected procedure or have an emergency. Your benefit dollars can add up over time. You can easily check to see how many rollover dollars you may have when you log into your Florida Blue member account. Check your policy to see if it includes Maximum Rollover.

Network

A dental network is a group of dentists under contract with your dental insurance carrier to provide services to their plan members at negotiated set rates (often at significant discounts). While many dental plans allow you to get care from out-of-network dentists, doing so usually means paying more for the services.

Nonparticipating provider

Nonparticipating providers are dentists who don’t have a contract with your dental insurance carrier to charge set rates. Treatment by nonparticipating providers almost always costs more than receiving care from participating providers.

Oral Health for Overall Health

Florida Blue dental and health plans work together to help you live healthier through our Oral Health for Overall Health^SM program. Members with eligible medical conditions get additional benefits—at no extra cost—that promote better overall health and can help reduce medical and dental expenses. Learn more about Oral Health for Overall Health. Check your policy to see if you’re eligible.

Out-of-pocket maximum

The out-of-pocket maximum is the maximum amount you’ll pay for covered services during a calendar year if you visit an in-network dentist. Once the out-of-pocket maximum is met, you’re no longer responsible for a deductible (if applicable), coinsurance, or copayment amounts unless otherwise specified in your plan.

Participating provider

A participating provider is a dentist or specialist who has a contract with a dental insurance carrier to charge set rates for services or products. Seeing these providers almost always costs less than getting care from nonparticipating providers.

Premium

The premium is the amount you pay monthly for your dental policy. You must pay the premium each month in order to maintain your coverage.

Prepaid dental plan

A prepaid dental plan is like an HMO (health maintenance organization) plan. The dental insurance carrier pays contracted dentists a fixed amount each month for every plan member assigned to them. The dentist receives a monthly payment whether or not an assigned member uses their dental benefits. In return, the contracted dentists must provide certain services to their prepaid dental plan patients at reduced or no cost.

Predetermination

A predetermination describes the review of a proposed treatment or procedure for medical necessity. It provides detailed information about coverage, such as the percentage covered, how the insurer will pay, and any deductibles or maximums. A predetermination is offered as a courtesy; it can help address coverage limitations before services are provided. However, a predetermination approval doesn’t guarantee claims payment.

Preferred provider organization (PPO)

Dental preferred provider organization (PPO) networks allow you to choose a dentist from your dental insurance carrier’s network of participating providers. These dentists contract with the carriers to charge plan members set fees for their services that are usually lower than their normal rates. You can see a dentist or specialist in or out of network, but your out-of-pocket costs will usually be lower when you see a dentist or specialist in the network. Dental PPO plans typically have a deductible that must be satisfied before payment of benefits can begin and an annual maximum amount that the insurance company will pay.

Preventive care

Preventive care describes all that’s involved with maintaining good oral health. In addition to brushing and flossing daily, regularly scheduled dental cleanings and exams can help prevent and detect conditions before they become more serious and expensive to treat later on. Learn more about preventive care.

Prior authorization

The prior authorization process confirms if your plan covers a recommended treatment or service. It’s required by some insurers for certain procedures. It allows providers to get approval from a payer for specialists and referrals. However, prior authorization doesn’t guarantee reimbursement or provide details about coverage, like the percentage covered or how the insurer will pay.

Special enrollment period (and qualifying events)

The special enrollment period is the period of time outside the annual open enrollment period when employers allow employees to obtain or make changes to group health and dental policies. The term is used to determine COBRA eligibility. You can sign up for a new health or dental insurance policy or change an existing policy during a special enrollment period if you experience a qualifying event. These events include relocating, getting married or divorced, having a baby, adopting a child, becoming a U.S. citizen, or if your household income is below 150% of the federal poverty level. Generally, a special enrollment period lasts for 60 days after the date of the qualifying life event. You can enroll in individual dental plans that you purchase directly from a dental insurance carrier anytime.

Service limitations

A service limitation restricts a covered service, such as how often you can receive a service or an age restriction. You can find more information about service limitations, exclusions, and other coverage details in your policy.

Teledentistry

Teledentistry offers you a convenient option to receive emergency dental care if you don’t have a dentist, cannot leave home, need care after hours, or are traveling. You can contact a licensed dentist virtually by smartphone, tablet, or computer with audio/visual capabilities. They will write prescriptions or refer you to a participating dentist near you or your regular dentist for further care as needed. BlueDental PPO and Florida Blue Medicare plans now include two virtual dental visits per calendar year at no added cost through TeleDentistry.com.

Waiting period

Some dental plans require you to wait for a period of time before receiving certain services. You’re responsible for 100% of charges for any service subject to a waiting period if you don’t meet the required waiting period.