Author Topic: Anyone has/had Aetna DMO dental insurance? Trying to figure out cost of crown  (Read 867 times)

LongPigeon

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Hi guys, longtime lurker but first time poster here. I would appreciate your thoughts and advice regarding this issue.

I'm in need of a root canal followed by (mostly likely) a dental crown. I have Aetna DMO, and per their schedule of benefits, the cost of a porcelain/ceramic crown should be $210, however the dentist I went to (in-network, chosen as my primary dentist as required by DMO plans) is quoting me around $1,200. They did have a $210 option listed, however they said that it's for a metal crown. Since my tooth is in the front, I need to get a color-matched porcelain crown.

I called Aetna a couple of times, however none of the reps were able to give me a straightforward answer. They did mention that the $210 is for metal, and I have to pay for the difference. However they had no answers when I brought up the fact that their schedule of benefits has porcelain listed as $210. One of the reps asked if it's a front tooth, and when I said yes, she said then it should be $210 for the porcelain since that's the standard for a front tooth. She offered to call the office then call me back, and of course, I didn't hear anything back.

My questions are:

1. I know insurance plans vary, but in your experience, how much was your crown with insurance? I feel like the $1200 I got quoted was not using my insurance benefits at all.
2. For anyone that had/has Aetna DMO, if I got the referral for a root canal from dentist A, can I go to dentist B (also in-network) for the crown afterwards? Or am I stuck with dentist A for the crown since the initially referral was from them?
3. I haven't been calling other dentist offices to ask about the cost because I'm pretty sure they are not going to quote me over the phone. Am I wrong? Should I call around?

Thanks so much!

Metalcat

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$1200 is the normal price for a crown, even for a "metal" crown, because they're made with gold, so they're actually more expensive than porcelain crowns.

The only "metal" crown option that I can possibly imagine being that cheap is a stainless steel crown, which is not a proper crown, it's a temporary measure that is a pre-formed shell that gets cramped onto a tooth, and are used almost exclusively on baby teeth. Although I have seen them used in a pinch on adults at homeless shelters.

These are wildly different things, but there is no universe where a proper, permanent, custom made crown costs only $210.

$1200 is a very fair price for a proper crown.

Cranky

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Our insurance, not Aetna, paid for half the cost of a crown, and I recall paying about $450 out of pocket. Our dentist was pretty reasonable, though - LCOL area, owned his building, etc.

LongPigeon

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Thank you to everyone that has responded. I agree that $210 seems low for a crown, however $1,200 when insurance is used also seems too high. The DMO plan limits which dentist I can go see, however there's no annual limit like with PPO plans (usually $1000-2000 per year I believe). When I see an in-network provider, I am only responsible for the coinsurance, which is a set amount depending on the procedure billed. Anything above that is covered 100% by insurance. That coinsurance for the porcelain crown is $210 for a front tooth. The Aetna agent I spoke to today suggested that I ask the dentist to get an estimate of cost, so that I can see the breakdown costs. I'm not sure if it is worth pursuing with the current dentist since they already told me it's $1,270 there.

I'm also curious for those that got root canal/crown before, how long was the gap for you between root canal and getting crown installed?

Any and all suggestions are appreciated!

Thanks again.

**edited to change wording
« Last Edit: August 24, 2021, 01:13:32 PM by LongPigeon »

Metalcat

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These would be questions for your dentist, but typically a crown is to prevent catastrophic fracture of the tooth after it's been structurally weakened by decay, root canal, etc. So there's no timeline, the risk of catastrophic fracture and tooth loss is immediate.

Your dentists either thinks that the crown is necessary to prevent tooth loss or it isn't, so if I were you, I would ask them for their rationale for recommending it. FTR, I have a crown on a front tooth from 20 years ago because I had a root canal, only to find out 10 years after I got it that I never needed it. Not all root canal treated teeth need crowns. My front tooth is actually now much, much more at risk for fracture because my front crown was done poorly. I'm in the process of having it fixed.

I don't know how US insurance works with dental, it's different in Canada, the cost here is the cost no matter what insurance you have, and then insurance pays whatever percentage the plan pays, but different insurance plans here don't have different prices, the price is just the price. Your insurance system confuses the fuck out of me.

Of course you can call around other offices and ask, they should all have a cash price that they should be willing to quote you, but you might not be able to get an estimate based on your personal insurance. You won't know unless you try.

tygertygertyger

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I'm not very familiar with DMO plans, but most dental insurance in the US has the following coverage: 

100% coverage for preventative care (cleanings, routine x-rays)
80% coverage for minor things (fillings, etc)
50% coverage for major (root canals, crowns, etc)

If your in-network dentist quoted you $1200 for a crown, I would anticipate that your max out-of-pocket cost would likely be $600, or perhaps a bit less if your dentist quoted you their standard rate (which is not the AETNA insurance-negotiated rate for a crown). Of course, you would be wise to confirm this against your insurance plan and with your dentist.

I agree that $210 is VERY unlikely to cover a crown. $1200 seems like a reasonable quote. 

Dave1442397

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I had a crown done under Aetna DMO four years ago, and I paid $540 out of pocket. I had another one done last December, same dental plan and dentist, and it also cost $540 out of pocket. On the second one, I see another charge for Crown buildup, at $143.20. No idea what that is...I guess something that had to be done before the crown could be installed.

Metalcat

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I had a crown done under Aetna DMO four years ago, and I paid $540 out of pocket. I had another one done last December, same dental plan and dentist, and it also cost $540 out of pocket. On the second one, I see another charge for Crown buildup, at $143.20. No idea what that is...I guess something that had to be done before the crown could be installed.

It's the filling underneath the crown. A crown needs a certain shape of structure to hold onto, if the tooth is broken or decayed, it doesn't have that structure, so that needs to be rebuilt before a crown can cover it and protect the whole tooth.

FiguringItOut

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I have DMO and paid around $800 for my replacement crown 2 years ago.  It wasn't a simple crown and required some gum work as well.  My doc is in network. 

Metalcat

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I agree that $210 is VERY unlikely to cover a crown. $1200 seems like a reasonable quote.

$210 would run a dental office about $800 in the negative on a crown. After all of the overhead, the profit for a dental office on a $1200 crown is about $200.