Much like snowflakes, no two mouths are the same. Because of that, no two dental visits are really the same either. That’s especially true when it comes to getting a crown.
Crowns are one of the most complicated dental procedures when it comes to insurance, simply because there are dozens of variables, which is good! That means you won’t be overpaying, but it does mean you’ll need a PHD to understand exactly what you’ll end up paying.
Well, a PHD or this article, because I decided I’m going to try to explain one of the most complicated things SDPEBA has to offer! Wish me luck!
Why is this so Complicated?
Mostly because there are a lot of different options depending on the severity of the damage to your tooth and the price for a crown. Basically, the amount of damage and the location of your tooth determines if you need a full crown, an onlay, an inlay, or a ¾ crown. The price varies further based on the material.
Your dentist will assess your needs on your visit and be able to tell you what material would work best, as well as, the type of “restoration” you’ll need.
After your dentist has checked your tooth and is beginning to make recommendations for treatment, we highly advise you to get an estimate for the cost of the procedure. For HMO plan-holders, ask your dentist for a pre-treatment estimate. For PPO plan-holders, ask your dentist to submit a claim form before going forward with treatment.
MetLife Dental PPO Plan
By and large, the PPO plan has a very simple structure (compared to the HMO plan) when it comes to getting a crown. You’ll pay 40% in-network (50% out-of-network) of whatever your actual dental bill comes out to be. This is where a claim form comes in handy, as your dentist’s prices might not reflect MetLife’s prices. On top of that, there might be discrepancies based on how many crowns you need, the types, and anything unique about your procedure. So please! Ask your dentist to submit a claim form so you know what you’re getting yourself into.
MetLife Dental HMO Plan
This is where the confusion starts. If you’re familiar with your HMO plan, you probably know that nearly every dental procedure is listed alongside a price in your Summary of Benefits. So, when you look at the crowns section, you’re greeted with a large description of different materials, locations, stipulations, and just too many words.
So. First things first. When you begin the process of getting a crown, talk to your dentist about your options. Usually, the dentist will offer you a “low, medium, or high” option. In most cases, the “low” option is based on your insurance, while medium and high are not. These options usually differ mostly in the type of material they plan to use.
Regardless of whether or not your dentist gives you options, be sure to ask specifically which treatment plan will be covered under by your benefits. You should also ask your dentist to submit a claim/treatment estimate to MetLife to get an idea of how much the procedure will cost. Most in-network dentists will do this automatically, but it’s always better to be safe than sorry!
Your dentist might ask for your “Summary of Benefits” or your “Explanation of Benefits” to get a code, you’ll find that information linked here. Crowns start on page 12.
How to Understand what’s going on, on Page 12…
We want to reiterate that you should discuss pricing with your dentist first and foremost, they’ll be able to give you a treatment estimate. But! If you want to have some vague idea of what things will cost before going in, you’ll need to do some addition.
On page 12 you’ll see a larger section titled: “crowns.” In that area there are two additional conditions that add onto the cost of your copayment, we’ll come back to that in a second, but it's important to keep in mind the price you see next to the service code is not one-to-one with what you’ll be paying.
Below the row titled “crowns” you’ll see a few dozen service codes, descriptions, and copayment amounts. This part is pretty straightforward, if you get any of those services, you’ll be paying that copayment on the right (per tooth).
Now! Here’s where things get tricky. The copay associated with that code might increase if it meets one of the conditions on the row above. For example, if you get a full-cast high noble metal crown (code D2790), you’ll have to pay an additional copayment up to $150 per crown (that price will vary, but it will never exceed $150). So, you’ll pay $100 for the service, and then up to $150 for the additional charge.
The same goes for adding seven or more bridges, crowns, or implants. Basically, if you need seven 3/4 porcelain crowns (D2783), you’ll need to pay $100 per crown ($700) and then an additional $125 per crown as well ($875). Meaning for these seven crowns, you’ll be paying $1475. Additionally, if any of those porcelain crowns are on molars, that’ll add an additional $75 per molar. Granted, most of our members don’t need seven crowns in a single visit, but its important to understand that materials, conditions, and circumstances matter when it comes time to pay your bill.
To make it simple, here’s an easy way to check your prices. Talk to your dentist and find out which material and type of crown you’ll need, ask them for a pre-treatment estimate. Use the summary of benefits document and look-up the services you’re planning to get and take note of the copayment for that service. If you’re getting a porcelain crown on any molars, add $75 per molar to the copayment. If you’re getting more than 7 crowns/implants/bridges, add $125 per unit. And if you’re using noble/high noble metal or titanium, add $150 per crown (remember, you might not actually pay $150, that’s just maximum. This varies based on the type of metal and the amount of material needed for your crown). Okay, maybe that’s not that simple. Check out the chart below to make it easier to calculate.