The Truth About Dental Insurance



Dental insurance plans are a contract between your employer and the insurance company. Your employer and the insurer agree on the amount your plan pays and what procedures are covered.

Your child may require dental care needs that are not covered by your plan.  Employers commonly chose to cover some, but not all of employees’ dental costs. If you are not satisfied with the coverage provided by your insurance, let your employer know.

“Your dental coverage is not based on what your child needs or what his or her dentist recommends. It is based on how much your employer pays into your dental insurance plan”


1. What does it mean when my insurance has an “Alternate Benefit” clause?

Your insurance plan may contain an LEAT (Least Expensive Alternate Benefit) clause. That means if there is more than one way to treat a condition, the plan will pay for only the least expensive treatment. However the least expensive option is not always the best.

Example: John needs 3 fillings on his molar teeth. The best option in most cases is a tooth-colored, mercury-free filling but your insurance plan may only pay for silver fillings.

Disclaimer: We do not use amalgam (silver filling) material at HTNY. If your insurance plan contains an LEAT clause, you may be responsible for additional co-pays.

2. What is the difference between an “in-network” and “out-of-network” doctor?

Your plan may want you to choose dentist from its “preferred” or “in-network” providers. These terms means that these dentists have a contract with the dental benefit plan. For a list of insurance companies Dr. Lal participates with click HERE.

If we do not participate with your insurance company, we are still happy to treat your child. Please call (212) 810-6562 to get more information about your out-of-network benefits. At this time we do not accept any state-funded dental plans.

3. How many routine checkups/cleanings will my insurance pay for in a year?

Your plan may limit the number of times it will pay for certain visits. This is called a “Frequency Limitation”. Some patients may need routine care or follow up visits more often to maintain good oral health. These additional visits are not covered.

Example 1: Judy’s insurance plan will only pay for two routine cleanings & two dental exams in one calendar year. Because Judy is considered a “high risk” patient (multiple cavities/ poor home care), Her dentist recommends 3 cleanings a year. Judy’s mom or dad will have to pay out-of-pocket for the 3rd dental cleaning.

Example 2: Janice’s had a filling 6 months ago at another dental office that fell out. Her insurance will not pay to have it fixed. Reason: Her insurance plan will only pay for fillings or sealants one time per tooth per calendar year. Janice’s mom or dad will have to pay for the replacement filling.

4. What happens if there is a problem with payment from my insurance?

Your insurance plan may “reject” a claim for multiple reasons. In these situations we will be more than happy to assist you in filling an appeal.  However, any balances left on the account are the patient’s responsibility.

We file most insurance electronically, so your insurance company will receive each claim within days of the treatment. You are responsible for any balance on your account after 30 days, whether insurance has paid or not. We will be glad to send a refund to you when your insurance pays us.

5. Why did I receive a bill (EOB) from my insurance company?

After your child’s dental visit you may receive an Explanation of Benefits (EOB) from your insurance company. Frequently, these EOB’s reflect a “patient balance owed”.  Your insurance company sends these notices prior to claim payment. If there are any outstanding balances that need to be collected you will receive a statement directly from our office or someone will call you to discuss the amount owed. If you’re not informed by a team member at Happy Teeth NY about any balance owed, please do not worry about the patient balance on your EOB.

6. What is a dental deductible?

A deductible is a specified amount of money that the patient must pay annually before an insurance company will pay a claim. Most of the time the deductible is not applied towards preventative services such as routine dental exams and cleanings. However, just like your coverage amounts, the amount of your deductible and the services it applies to are chosen by your employer.

Example: Joe needs to have one of his baby teeth extracted (cost $100). His insurance plan will pay 80%  ($80) after he has paid his $50 deductible. Joe’s mom or dad is responsible for his 20% co-pay ($20) and his $50 deductible.

Most insurance plans have an individual deductible and a family deductible. If the family deductible has been satisfied you will not have to pay a deductible

Example: Jada needs a baby root canal. Jada’s dental plan has a $50 individual deductible and a $150 family deductible. Her mother, father and brother have all had dental treatment done within the year and have paid their $50 individual deductibles. Therefore $150 has been paid towards the plans family deductible and Jada will not have to pay her individual deductible in the same year.

7. What is A Co-Pay?

Your co-insurance or co-pay is the amount your insurance company will not pay. You must be familiar with your insurance benefits, as we will collect from you the estimated co-pays at your child’s dental visits. We at no time guarantee what your insurance will or will not pay on each claim.

8. What if my child has two dental insurance plans (through my spouse and myself)?

In the insurance world the terms that applies to patients that have more than one dental plan is “Coordination of Benefits (COB)”.

Even though your child has two or more dental benefit plans, there is no guarantee that all of the plans will pay for the services he or she needs. Each insurance company handles COB in its own way. Please check your plan or contact our office for details.

Website Disclaimer

The information offered on our website is for education only and is not meant for diagnostic purposes.