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Your Medical Insurance Questions Answered

What you need to know when it comes to your coverage

Article Courtesy of SoundBridge Dental Arts and Sleep Therapy

It is important that patients are keenly aware of their insurance benefits. Insurance is an important factor in our patients’ care. In our practice, we utilize dental insurance if you are having any type of dental treatment completed by Dr. Bloomquist and medical insurance if you are seeing Dr. Iregui for an oral sleep apnea appliance. In the second part of this two-part series, we address some of the most common medical insurance-related questions we are asked.

Is oral appliance therapy for obstructive sleep apnea covered under my medical or dental insurance?

Oral appliance therapy is covered under your medical plan only. Obstructive sleep apnea is a medical condition and therefore it is your medical insurance company that will provide benefits for this treatment. Your insurance coverage is a contract between you and the company supplying your coverage, and to receive the benefit you are entitled to, you should know the specifics about your plan.

Are all medical insurance companies the same when it comes to coverage?

No, all insurance companies are not the same. There are even numerous plans within the same insurance company. The company that holds your insurance plan and the plan within that company that covers your medical treatment is either chosen by you or your employer. It is your specific plan that dictates your coverage and out-of-pocket expense for any medical procedure.

Are in-network benefits the same as out-of-network benefits?

An in-network provider is a provider who has signed a contract with your insurance company that they will provide treatment/services at a reduced cost. This means that the insurance company dictates what services are covered and at what reimbursement. An out-of-network provider, however, is still able to treat patients but because they are out of network, the fee schedule and treatment provided is set by the provider.

Each insurance has different policies regarding in and out of network benefits. Some plans do not even have out-of-network benefits. However, it is important to know that in some circumstances you can request a waiver, called a PPO waiver, in order to be seen by an out-of-network provider but receive in-network benefits. The PPO waiver must be approved by your insurance company prior to you moving forward with treatment. This waiver does require some leg work on the part of the insured, but most patients find that it is worth it.

What is secondary insurance?

Secondary insurance is the insurance plan that will possibly cover a medical visit or service after your primary insurance has been billed for your medical service and submitted their payment amount. Some secondary medical insurance plans do have deductibles that need to be met prior to them reimbursing your provider. There are also some plans that carry co-insurance as well. Patients need to check with their plans in order to get this information.

What is the difference between deductibles, co-insurance and co-pays?

A deductible is how much the insured person must pay out of pocket before insurance will start to pay for medical treatment. Co-insurance is a percentage of a medical charge that you pay with the remaining amount being paid by your insurance company. Co-insurance does not go into effect until your deductible is met. Copays are a fixed amount for a covered service. This is paid by the patient to the provider prior to or immediately after receiving a service. The amount of an insured person’s copay is defined by their policy.

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