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Personal Dental Insurance in Ontario, Canada - The Ultimate Guide

Why Personal Dental Insurance Is Important:

Personal dental insurance can help pay for your routine dental procedures such as cleanings, exams, x-rays, and check-ups as well as unexpected and expensive major procedures. Expensive dental procedures can include periodontal services, endodontic services, oral surgery, crowns, bridges, dentures, orthodontics and more.

In terms of the dental insurance plans available in the personal or individual insurance market, there are only a few insurance companies that offer “dental only insurance plans”. If you are self employed, there are more options available to you. The dental insurance plans that are available will, however, have a base level of extended health care coverage built into them. The focus of these plans is dental coverage, which is why they do not include prescription drug coverage and only offer minimal health coverage.

Before considering any coverage, it is important to deal with a dental insurance broker who will work with you to understand your needs, goals, and budget. A dental insurance broker will ideally be an independent insurance broker who offers products from multiple insurance companies. The broker will be able to compare various products from multiple insurers and work with you to find the ideal solution that is best suited for your unique needs.

Won’t the Government Pay My Dental Bills?

The government insurance plan, called the Ontario Health Insurance Plan (“OHIP”) in Ontario, does not cover routine dental care. Children under the age of 17 may be eligible for regular dental care under the Healthy Smiles Ontario Program. However, unfortunately not everyone is eligible to take part in this program. For most people, OHIP offers very limited coverage. The coverage offered by OHIP is only for complex dental surgery, and only when the surgery is performed in a hospital setting. This means, most of us are left to either pay for dental expenses out-of-pocket or, alternatively, to buy a personal dental insurance plan.

The Importance of Oral Health:

There are many reasons to pursue good oral health, from actual health to beauty and appearance. Poor oral health is said to affect your overall general health and well being. Gum disease is said to be the most common dental issue in adults. Cavities and gum disease have been linked to diabetes, respiratory illness, cardiovascular disease, and other health issues. Untreated dental problems can be painful and can lead to more serious infections.

Your first line of defence starts at home, with daily brushing and flossing. An antimicrobial mouth rinse may help reduce bacteria in your mouth as well. Diet, smoking, alcohol consumption and other factors are also said to affect your oral health.

Beyond home dental care, it is highly advisable to visit a dental professional regularly for exams, cleanings and any other oral health problems that come up. It is highly recommended to visit your dentist at least twice every year.

If you are looking for more information on oral health, please visit the Ontario Dental Association and The Canadian Dental Hygienists Association.

Understand What You Are Buying:

As a perceptive consumer, you should take the time to understand the details of any plan in which you are considering. There are many options available with different insurance companies and they are not the same. An insurance broker can always help you if you choose to deal with one, rather than going directly to an insurance company. An insurance broker will be able to help find the best plan for your needs and budget, help you understand your policy, help you submit claims, make changes, and step in to deal with any issues that may arise. Insurance brokers are paid a commission, but the price you pay typically stays the same as it would when dealing directly with an insurance company.

How dental insurance claims are paid will depend on the insurance contract, or plan that you sign up for. The insurance contract will state factors such as maximums, the co-insurance levels, deductibles, the fee guide used, the services that are covered, limitations and exclusions, and frequency limitations. Dental insurance contracts vary from plan to plan and though they may cover the cost of many dental expenses, they will not pay for everything.

Dental Insurance Plan Design, Features, and Details:

The following is a general overview of the more common points our clients ask us about.

Covered Services:

Typically, personal dental insurance plans have three tiers, basic (preventative or routine), comprehensive (extensive) services, and major restorative services.

The plan you choose may or may not cover all areas of service and some plans do not offer orthodontic services at all.

Below is a quick breakdown of what is generally included in these levels of coverage. Each Insurer’s specific services may vary, and they will describe the areas of service using different language such as basic, enhanced or base, bronze, silver, gold or by names like zone 1 and zone 2. This can create confusion for someone who is trying to compare different options from different insurers and again is an area that an independent insurance broker can help decipher for you.

  • Basic Services
    • Complete oral examinations
    • X-rays
    • Recall examinations
      • The term recall refers to the number of checkups that will be covered in a year which is typically either at 6-month intervals or 9-month intervals.
    • Cleanings
      • Preventative cleaning of teeth will typically include a set number of units for polishing and scaling. The number of cleanings will coincide with your plans’ recall schedule.
    • Fillings
    • Scaling
      • Each insurer has a maximum allowable number of scaling units that they will cover. A unit is equal to 15 minutes of service.
    • Polishing
    • Select, simple extractions
  • Comprehensive and Extensive Services
    • Oral Surgery
    • Endodontic services
      • Root canal therapy, pulpotomy, pulpectomy, apexification, root amputation, emergency procedures including opening or draining of the gum/tooth and more.
    • Periodontal services
      • Periodontal scaling and or root planning, occlusal equilibration, and related services.
    • Adjunctive services
    • Anesthesia
      • In conjunction with an eligible surgery.
    • Space maintainers
    • Denture cleaning, repair, relining, rebasing, adjustments and more
  • Major Restorative Services
    • Dentures
    • Crowns
      • Standard onlays or crown restorations.
    • Bridges
      • Standard bridges, crowns on natural teeth and more.
    • Orthodontics
      • Orthodontics coverage is only available with specific plans from select insurers.

Personal dental insurance plans that include major restorative services will allow you to start claiming the services in the third year of your plan. This means you must have the plan in force for two (2) years before you can start making claims in this area of services.

Bonus Health Benefits:

As previously mentioned, though a personal dental insurance plan is geared towards dental services it does offer some extended health coverage as well. Below are some of the included extended health care benefits which can be looked at as a bonus when buying dental insurance. These are a general overview and will vary by insurer and plan, as will the coverage levels.

  • Accidental dental
  • Ambulance
  • Accidental death and dismemberment
  • Hearing aids
  • Homecare and nursing
  • Medical equipment
  • Orthotics
  • Surgical brassieres
  • Wigs
  • Paramedical services
    • Acupuncture
    • Chiropractor
    • Naturopath
    • Physiotherapist
    • Psychologist
    • Registered massage therapist
    • Speech therapist
    • Osteopath
    • Chiropodist/Podiatrist
    • Eye exams
    • Vision coverage
    • Travel coverage
  • Survivor benefit

Co-insurance:

Co-insurance or co-payment is a form of cost sharing between an insurance company and the insured. For example, 80% co-insurance typically means that the insurance company will pay 80% of a claim and you (the insured) will pay the difference, 20%.

With most personal dental insurance plans, you will find that the co-insurance level for basic services increases after two (2) or three (3) years.

For example:

Year 1: 50%

Year 2: 70%

Year 3: 80%

As well, major dental services are covered from year three (3) and beyond. Depending on the insurer, the co-insurance level will be either 50% or 60%.

Better plans will typically have higher co-insurance levels.

The varying levels of co-insurance and the number of options from different insurers can make the plans difficult to compare. An independent insurance broker can help find the plan that is ideal for your needs and budget.

Annual Maximums:

Understanding the annual maximum coverage levels when comparing plans requires careful attention to the details:

One of the better plans available offers a combined anniversary year maximum as follows:

  • Year 1: $750
  • Year 2: $1,000
  • Year 3: $1,200
  • Year 4 $1,200
  • Year 5+: $1,500

A similar plan from another insurer offers a combined anniversary year maximum as follows:

  • Year 1: $600
  • Year 2: $800
  • Year 3+: $1,000

Some plans also have separate maximums for basic services and major services.

Keeping in mind that the co-insurance levels tier up each year until they reach their peak level of coverage. As well, that major services are not covered until year three (3) and beyond.

It is important to note that some plans may also contain a lifetime maximum such as $100,000.

Dental Fees and Fee Guides:

Each provincial dental association sets an annual recommended fee guide schedule, which lists the recommended charge for each dental procedure. The Ontario Dental Association (“ODA”) fee guide is a reference point of suggested fees for dental services in Ontario which are performed under normal conditions by general dental practitioners. The fee guide is update annually by the ODA. Most dental insurance plans will pay claims up to the current ODA fee guide in effect at the time the services are rendered. The payment is, of course, going to factor in any co-payment, maximum or other factor applicable to the specific claim.

The ODA fee guide had an average overall increase of 2.0% in January 2016, 1.65% in 2017 and 1.86 in 2018.

In provinces with more than one fee guide, the insurer will typically reimburse according to the least expensive standard fee, or fee range.

If independent dental hygienists are covered, the insurer will typically cover the current Dental Hygienists Association fee guide in your province of residence.

Every dentist sets his or her own fees as they must consider factors for their own specific business and patients. The ODA fee guide is developed to help dentists set their fees, although, it is only a guide and the fees are suggested. A dentist can charge fees above and below the fee guide.

Once a dentist establishes their fees for a specific service (with exceptions) they will charge the same fee to all patients, whether the patient has or does not have a dental insurance plan. A dentist could, however, charge more for complex and time-consuming cases and they could charge less for simple and less complicated procedures when comparing said cases to their norm.

Typically, any treatment rendered by a specialist will be reimbursed in accordance with the fee guide for general practitioners, or the normal fee guide.

It is important to note that laboratory fees are not dental fees and are in addition to the dentist’s professional fee for the treatment being provided. A personal dental insurance plan will only pay for laboratory charges in conjunction with other services.

Claims:

Generally speaking, reimbursement will be made for eligible services prescribed by and given under the direction of your attending legally qualified dental or medical practitioner. The eligible services must be medically necessary and reasonable and customary.

Again, your insurance contract will stipulate what is covered, what is not covered, how claims are paid, how much is paid the insurer, how much of the payment you are responsible for, further procedures, exclusions, limitations and so on.

Most dentists and virtually all insurers are setup for electronic claims submission. Through this process, claims are sent electronically, eliminating the need for paper submission.

Some dentists will require you to pay for your full bill and wait for reimbursement from your insurer. Other dentists allow you to simply pay the difference between the amount reimbursable by the insurer and the charges incurred. The second option is easier for you, the patient, and is called assignment of benefits.

Assignment of benefits is when you instruct and insurer to make a payment of allowable benefits directly to your dentist.

When submitting claims, insurers have the right to audit your claims and as such you should always keep organized records with original receipts. You may want to keep records filed away for a couple of years should an audit be enforced, this will save you a lot of time and grief should you need to find records that have been requested.

Reimbursement can be made by cheque, direct deposit, or direct payment to the provider of the services (assignment of benefits), where applicable.

All claims must be submitted no later than twelve (12) months from the date that the eligible benefits were incurred.

Coordination of Benefits:

Individual, or personal insurance plans are considered to be supplementary or secondary to other coverage. After benefits payable by government plans have been determined, excess benefits available are coordinated with benefits under other policies. How the insurer calculates the benefit payable under the individual plan when coordinating with coverage from another insurer’s plan (such as group benefits) may differ from one company to another. Whichever way the plans are coordinated, total reimbursement should never exceed 100% of the expense being claimed.

At the end of the day, it always best to refer to your policy wording to determine who is the primary payor first and consult your insurance broker or insurer for further clarification specific to your own circumstances.

Common coordination of benefits for a family may be coordinated as follows:

  • For your own plan:
    • Your own insurance plan will pay your claims first; and your spouse’s plan will pay your claims second.
  • For your spouse’s plan:
    • Your spouse’s plan will pay their claims first; and your own plan will pay your spouse’s claims second.
  • If both parents have their own insurance coverage and their dependents are covered under both plans as dependents, then the plan of the parent with the earlier birth date in the calendar year will pay first.
  • Though not as common, if both parents have the same birth date, the parent with the name that occurs first in the alphabet will pay first.

Predetermination of Benefits:

Insurers require submission of an estimate in advance for extensive dental work that may be performed. Your insurance contract will specify the amount required for a predetermination of benefits. Once your dentist submits the estimate to the insurer, the insurer will respond with an outline showing what they will pay and the amount that you will be required to pay.

This process gives you the opportunity to further discuss the recommended procedures with your dentist.

You will also not be surprised with a large bill to be paid out of your pocket. As well, dental offices occasionally miscode services, and the insurer would in these cases, deny an expense that would be covered. While this is not common, it is worth reviewing with your dental office, as it could make a significant difference regarding how much you are required to pay out-of-pocket.

An insured who fails to obtain an estimate per their insurance contract requirements will not typically be refused reimbursement. However, the amount may not be the full expense amount if the claims adjudicator assesses the rate to be more than commonly charged or if the procedure is seen to be more extensive than required. Insurers often make use of professional consultants in reviewing claims to determine whether a lower-cost alternative treatment may have been of equal therapeutic value.

Was Your Claim Limited Or Declined?

The first thing that you want to do is carefully read the explanation of benefits from your insurer. The explanation of benefits typically explains how the benefits were calculated and will contain a code and explanation as to how the insurer came to their decision.

Benefits can be declined due to the terms of your plan, hitting maximums for the year, and can include many other factors.

If you feel that a claim should have been paid based on the information at hand it best to consult your independent insurance broker who can examine the details of your claim. It may be that the insurer is correct in not paying a claim, in which case your broker can explain why this may be. If your broker feels your claim should have been paid, they can advocate on your behalf with the insurer to try and get your claim paid per your contract terms. If you deal directly with an insurer than you are at the mercy of their staff who will proceed in an appropriate fashion, however, it is possible that they could make a mistake or be wrong (we have experienced this). Without a broker to step in for any issues, you are dealing directly with the employee from the company that is denying your claims and not an independent third-party that works for you, your insurance broker.

Alternative Benefit Provision:

An alterative benefit provision provides the insurer with the right to consider an alternative procedure, service, course of treatments and materials, and to provide benefits based on the least costly thereof which would produce a professionally adequate result, consistent with accepted standards of dental practice. The fact that a similar procedure, service, course of treatment or material may have been previously used will have no bearing on the provision. This is not necessarily a bad provision as an alternative and adequate service could be provided to a patient at less out-of-pocket cost to them.

Limitations and Exclusions:

Every insurance policy will have limitations and exclusions. As an informed and smart consumer, you should always read these thoroughly to understand any limitation or exclusions your policy may contain.

In addition to standard exclusions for health benefits, dental benefit exclusions may exclude treatment for cosmetic purposes only, treatment for a dental hygienist not working under the supervision of a dentist, services covered by a government plan or workers’ compensation and any services related to dysfunction of the temporomandibular joint (TMJ).

Increasing or Decreasing Coverage:

When your budget or needs change, it may be necessary to consider better insurance coverage or lower premiums and coverage.

Some plans will require that you apply to increase coverage by providing evidence of good health. This would be in conjunction with an application for the new coverage. It may not be necessary to provide evidence of good health if the plan is dental focused.

If you are increasing or upgrading your plan, any used benefits will typically be applied against your new plan maximums.

Should you wish to reduce your coverage, the insurer will typically allow you to do so, as long as you have been insured for your current plan’s required minimum amount of time, such as twelve (12) months.

Premiums:

The first premium is typically due in advance of the effective date and thereafter, one (1) month in advance. Most plans will ask for first and last month’s premium up-front, like rent.

A personal dental insurance plan is a month-to-month plan. If premiums are not paid when due, coverage will terminate at the end of the last month which premiums were paid and accepted by the insurer.

The Dental Insurance Contract:

Insurance contracts tend to be complex and extensive. Though there is a lot of information, it is extremely important to read and understand the contract that you are buying, before you buy it. An insurance broker will be able to help you with this process and save you a lot of time and research.

As with any insurance contract. The contract is issued in consideration of the statements made by you in your application and payment of required premiums.

The insurer will pay for your incurred charges as described in the contract and the charges will be subject to any exclusions, limitations and conditions stated in the contract and/or amendments to the contract.

Further Definitions:

Effective Date:

A dental insurance policy will typically become effective on the first day of the month following payment. If you are setting up a plan very close to the end of the month, it could potentially be issued a month later.

Eligibility:

To be eligible for a health and dental insurance plan in Ontario, one must:

  • Be covered under your provincial/territorial health insurance plan, such as OHIP;
  • Be a resident of Canada; and
  • Be at least 18 years of age on the date of the application for the policy, unless you are a dependent child of a plan member

Anniversary Year:

Anniversary year means the consecutive twelve (12) month period following the effective date of the policy, and each twelve (12) month period thereafter.

Benefit Year:

Benefit year means the consecutive twelve (12) month period following the date a claim is incurred. It can also be defined as the twelve (12) consecutive months commencing on the effective date of coverage, and each twelve (12) month period thereafter.

Calendar Year:

Calendar year means the twelve (12) month period commencing January 1st and ending on December 31st.

Dentist or Denturist:

A Dentist or Denturist means a practitioner of dentistry lawfully qualified and licensed to practice in the jurisdiction in which he or she has provided the services or supplies for which the charges are incurred.

Eligible Expenses:

Eligible expenses are expense incurred by an insured that are payable by the insurer based on the provisions, terms limitations and exclusions of their own specific policy.

Effective Date:

The effective date is the day on which coverage under your insurance contract takes effect.

Government Plan:

A government plan is any plan or arrangement provided by or under the administrative supervision of any government or agency which provides coverage or reimbursement for any health care service or supply, including but not limited to the Ontario Health Insurance Plan, home care program, assistive devices program or workplace safety and insurance board or tribunal of the covered person’s province of residence.

Medically Necessary:

Medically necessary means a treatment, service or supply which is generally accepted by the medical profession as essential, effective, and appropriate in the care and treatment of a medical condition, sickness, or injury.

Spouse:

A spouse is a person who is covered under a government health insurance program (“OHIP”) and to whom the insured is legally married or with whom has cohabited in a conjugal relationship for at least 12 consecutive months (common-law).

Usual, Reasonable, and Customary:

Usual, reasonable, and customary means, in relation to charges, the usual charge for a service given or supplied by a provider (“usual”); those charges which are consistent with representative fees and prices which would normally be made in the absence of coverage under your insurance policy (“reasonable”); and that range of usual charges by providers with similar expertise and services with the geographic area (“customary”).

Dependent:

A dependent is a child of the insured who is listed on their application and who is a natural child, adopted child, stepchild, foster child, or a child for whom the insured is by law responsible, who is unmarried, unemployed, and dependent on the insured for financial support and is under 21 years of age.

This article is simply a guide and we hope that is of help to you, but one must always refer to their actual insurance policy wording. If you are unsure, please consult the appropriate professional regarding your specific questions.

Get a personal dental insurance quote and apply online:

Get an instant dental insurance quote online through CT Insurance Brokers Inc. and the Manulife Association Health & Dental Plan.

Looking to learn about personal health insurance?

Visit our personal health insurance article for more information.

Personal Dental Insurance Guide - Ontario, Canada

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