Brushing and flossing are key to your dental health. So is choosing the right dental coverage.
While dental insurance doesn’t command the attention that medical insurance does, it also can have significant implications for your pocketbook.
You know exactly what I mean if you have the most common type of health insurance (more on that later) and have ever needed a procedure such as a crown or root canal.
Read: $$$$
More than 19 million Californians had commercial dental insurance in 2014, and most of them obtained it through their employers, according to the National Association of Dental Plans (NADP). 
But “in a way, it shouldn’t even be called insurance,” says Jeff Album, a vice president at Delta Dental, California’s largest dental insurer.
Album prefers calling it “a prepaid plan” for preventive and basic services, such as cleanings and fillings.
If you need a more complicated procedure, “you’re going to end up paying a big part of the bill out of pocket,” he says.
Today I’m offering five tips on how to best use your dental benefits to save you money and frustration.
CHOOSE THE RIGHT PLAN
There are two primary types of dental plans: HMOs and PPOs.
The vast majority of Californians with commercial dental coverage —  more than 14 million —  have PPOs, the NADP says.
Here’s how a dental PPO works:

• In addition to your monthly premiums, you may owe a deductible before your insurance kicks in. Deductibles typically are under $50 and generally aren’t applied to preventive services, Album says.
• You face annual limits on your coverage, typically between $1,000 and $2,000, which is the maximum your insurance will pay out in one year.
• Twice-yearly cleanings and other preventive services are usually fully covered. You’ll pay a percentage of the cost for other services, such as 20 percent for a filling or 50 percent for a crown. Which adds up fast.
  A dental HMO operates differently.

• Your premiums will be lower.
• You probably won’t have deductibles or benefit maximums.
• You’ll pay fixed copayments for treatments.
  However, with an HMO, “your choices of dentists is much, much smaller,” Album says.
  How much smaller? About 90 percent of California’s practicing dentists participate in PPOs, whereas about one quarter participate in HMOs, the NADP says.
  You may also have fewer treatment options with an HMO, says Long Beach dentist Gary Glasband. For example, an HMO may agree to cover a metal crown. But if you prefer a ceramic crown that blends in with your other teeth, you may have to pay an additional cost, he says.
  “You’re going to look at this choice differently if you’re a 20-year-old who has very little dental needs compared to someone who needs complex work,” he says.
  If you have children, consider whether the plan covers orthodontic benefits, Glasband adds.
  Once you’ve chosen your plan, understand your coverage. For instance, if your plan covers two cleanings a year, can they occur at any time or do they have to be more than six months apart?
  “One cleaning every six months is not the same as two cleanings a year,” Glasband says.
  STAY IN NETWORK
  You will spend the least amount out of pocket by staying in your dental plan’s network, whether you have an HMO or a PPO.
  With an HMO, you usually won’t receive any coverage out of network.
  In the case of a PPO, you will receive the highest level of coverage from an in-network dentist plus reduced rates on the amount you have to spend out of pocket, Album says.
  If you opt for an out-of-network dentist, you will still receive coverage, but at a reduced level.  
  Once your dentist has determined your treatment, always request a pre-treatment estimate from your plan. That will help you determine how much you’ll owe, Album says. 
  TIMING IS EVERYTHING
  Schedule your procedures to make the most of your dental coverage.
  Let’s say your dentist recommends four fillings and two crowns. If you do them all at once, you’ll likely exceed your maximum benefits and spend hundreds of dollars (or more) out of pocket.
  If it’s not an emergency, find out when your annual benefits renew, Glasband says. For most people it’s Jan. 1.
  In that case, Glasband suggests getting two fillings and a crown in November and the remaining procedures early the following year, which essentially doubles the amount of coverage at your disposal.
  “Count on your dentist to help you time your benefits,” Album says.
  DISCOUNT PLANS
  If you don’t have dental insurance, consider purchasing a discount dental plan. These plans, which are not insurance, give you access to certain dentists who have agreed to perform procedures at discounted, cash prices.
  The discounts are usually 20 to 30 percent, sometimes more, says Evelyn Ireland, executive director of the NADP.

If you haven’t experienced it yourself, you’ve no doubt heard about the outrageous — and rapidly growing — prices of certain prescription medications.

The average price of about one year of cancer-drug therapy has skyrocketed from $10,000 (or less) before 2000 to more than $100,000 by 2012, according to a recent Mayo Clinic study.

The new hepatitis C drug Sovaldi comes at a retail price tag of $84,000 for a 12-week course.

Prices are even spiking for some generics that have been around for years. Take the cost of the commonly used antibiotic, doxycycline, which jumped from $20 for 500 pills in Oct. 2013 to $1,849 in April 2014, according to AARP.

The unaffordability of drugs is a real and growing threat, even for people with health insurance.

Today I’m going to offer some tips on how to save money on your prescription drugs, whether you’re insured or not.

Q: I was recently diagnosed with cancer and had my first round of chemo. The nurse gave me a prescription for a generic anti-nausea medication. When my wife took it to the drug store, she was quoted a price of $900 for a 30-day supply. How is that possible?

A: I wish I could answer the question from Jim Buchanan of Hemet, but I don’t know why a generic anti-nausea drug would cost $900 out of pocket, even with his insurance applied to the prescription.

I can say that his wife, Susan Buchanan, did the right thing when she didn’t take $900 for an answer. Though “totally in shock” from the quoted price, she asked what the cost of the prescription would be without applying insurance.

$45.

Counterintuitive? Yes. Confusing? Definitely.

“In some cases, people may be better off not using their insurance,” says Betsy Imholz, special projects director at Consumers Union.

Lesson 1: Shop smart.

When you get your prescription, call multiple pharmacies and negotiate, even for generics. Neighborhood pharmacies may have more autonomy to lower prices than chain stores, Imholz says.

If you don’t have insurance, however, Costco has the lowest price of chain stores on average, she says. You don’t have to be a member to use its pharmacy.

Finally, ask your doctor to write a prescription for a 90-day supply of drugs instead of 30 days. “You’ll be avoiding copays and trips to the pharmacy,” she says.

Lesson 2: Appeal for coverage.

Let’s say your doctor wants you to take a medication that’s not on your plan’s formulary and you’re faced with paying full cost. 

Before you empty your pockets, file an appeal with your insurer, which in most cases must cover medically necessary drugs that aren’t on their formularies— if your condition warrants their use.

If your health plan rejects your appeal, contact your regulator and request an independent medical review, which is free. The health plan’s denial letter will specify your regulator, or try the state Department of Managed Health Care (888-466-2219 or www.HealthHelp.ca.gov) or the state Department of Insurance (800-927-4357 or www.Insurance.ca.gov). 

You’ll need to work with your doctor through this process to help you prove medical necessity.

Lesson 3: Look for financial assistance.

There are a slew of programs offered by drug companies and foundations, and many websites that help you search for them. One is NeedyMeds (www.NeedyMeds.org), a national nonprofit that helps connect people with assistance.

“Pharmaceutical companies give away billions of dollars in drugs every year to people in need,” says NeedyMeds President Richard Sagall.

Financial help from pharmaceutical companies is generally for brand-name drugs that don’t have generic equivalents. These programs have eligibility requirements based on four categories, Sagall says:

• Citizenship and immigration status.
• Some will only help people who are uninsured or have no drug coverage.
• Income. Many have relatively generous thresholds that include middle-class families.
• Some are disease- or diagnosis-specific.

All require some input from the doctor who prescribed the medication, Sagall says.

If you have drug coverage but can’t afford your copay, there are programs that may help with that, too.

Other helpful websites for financial assistance include the Partnership for Prescription Assistance (www.pparx.org); Patient Services, Inc. (www.PatientServicesInc.org); and the Patient Advocate Foundation’s National Financial Resource Directory (www.PatientAdvocate.org).

You can also reach out to disease-based organizations like the Leukemia & Lymphoma Society or the American Diabetes Association.

Lesson 4: Use prescription discount cards and programs.

There are two types of drug discount cards. The first comes from pharmaceutical companies and generally offers discounts for a specific drug, Sagall says.

The other discounts multiple drugs and is offered by AARP, Costco, NeedyMeds and others. However, “you cannot use these in conjunction with insurance or state-federal programs such as Medicare,” he says.

But don’t forget the Buchanans of Hemet, who got a better deal without their insurance.

Lesson 5: Choose insurance with drug coverage you need.

One of the best ways to limit your out-of-pocket costs is to choose the best plan for your situation. You’ll have a chance to do that in your next open-enrollment period, which is fast approaching for most people.

If you have a chronic condition or take a lot of medications, try to avoid high-deductible plans, which include the “bronze” level plans sold by Covered California.

“If you have to pay a little higher premium but have lower out-of-pocket costs, that’s a better choice,” says Liz Helms, president/CEO of the California Chronic Care Coalition.

Electronic cigarettes (e-cigarettes) are marketed as a safer alternative to traditional cigarettes and a way to manage nicotine cravings if you’re trying to quit. But here are 3 good reasons to give them a thumbs down.

1. Safety concerns
After analyzing e-cigarette samples, the U.S. Food and Drug Administration (FDA) found that some products contain cancer-causing agents and toxic chemicals such as diethylene glycol, an ingredient used in antifreeze.

2. No convincing evidence they will help you quit
In fact, there is evidence suggesting the opposite: A 2014 study by researchers at the University of California, San Francisco, revealed that smokers who use e-cigarettes are a third less likely to quit than those who don’t use them.

3. What’s proven to work still works
Evidence shows the most effective way to quit is to use a combination of FDA-approved medications (like the nicotine patch, gum, lozenge, or bupropion) and counseling support. Choose what works for you: Kaiser Permanente’s Wellness Coaching by Phone, tap into the power of a group in a Health Education stop smoking class, or try the online, self-paced program called HealthMedia® Breathe.(TM)

By Emily Bazar of the OC Register, very good info-

Last year, I developed an antibiotic-resistant infection on my arm when traveling on the East Coast. With each day, it grew scarier and more painful, and it was spreading.

Like a good girl, I called my health insurance company here in California and they pointed me to specific urgent care clinics, assuring me I’d have to pay only my regular office copay ($20), even though I was visiting an out-of-network provider.

More than a year later, I am still battling the insurer, which billed me the out-of-network price. To add to this infuriating saga, the health plan sent me into collections.

I have devoted recent columns to the limited doctor and hospital networks that accompany some of your new health plans. This has spurred several of you to ask if you’ll be billed for going out of network when you need emergency care,especially if you’re not in your hometown when the emergency happens.

As my example shows, this issue predates Obamacare. But with more Californians insured, some by plans with narrow networks, I wouldn’t be surprised if, like me, more of you have to duke it out with your insurer.

Read on.

What are the best strategies for addressing emergency situations given network and out-of-network coverage? If you are in a car accident, is there any way to avoid bankruptcy?

In theory, it shouldn’t matter much whether you visit a network or out-of-network emergency room if you have a medical emergency. You may not even have a choice if you’re suffering a heart attack or in other real trouble. The ambulance will take you to the closest ER that can handle your situation.

In reality, however, your bill will depend on what kind of health plan you have and which state agency regulates your plan.

There are two California agencies that regulate health insurers and their products: The state Department of Insurance (CDI) and the Department of Managed Health Care (DMHC).

Why we have – or need – two is fodder for another column. For now, what’s important is that the CDI regulates most PPO and EPO policies and DMHC oversees managed care policies, but also some PPOs and EPOs. (To find out which agency regulates your plan, call the CDI consumer hotline at (800) 927-HELP.)

No matter which agency regulates your plan, the federal Affordable Care Act says you will be charged the same copay (a flat dollar amount) for visiting an out-of-network emergency room as a network one, said Janice Rocco, CDI deputy commissioner.

If your share of the bill comes in percentages instead, you will be charged the same ratio (say 20 percent) regardless of the ER’s network status. In these circumstances, however, you may face a higher dollar amount because your insurer may not have negotiated rates with out-of-network ERs or physicians as it has with network ones, Rocco noted.

In plain terms, that means you may be billed 20 percent of $10,000, for instance, instead of 20 percent of $2,000.

That’s not the worst of it for roughly 10 percent of Californians whose plans are regulated by the CDI. Ever hear of “balance billing”? Sometimes health plan and the hospitals/doctors that provide services don’t agree on the amount that providers should be paid.

“ Balance billing” occurs when doctors and/or hospitals bill the consumer directly for the difference between what the plan pays and what the medical providers think they’re owed.

If you have a CDI-regulated plan, you may be “balance billed” for out-of-network use.

Dr. Tom Sugarman, a Bay Area emergency physician, provides an example: Let’s say you show up in the emergency room with a complex fracture and the ER doctor needs to call in an orthopedist. Even if you’re at a network hospital, that orthopedist may not be in your network.

Sugarman said insurance companies often don’t pay enough to cover the services of specialists, so you may be balance billed.

“Physicians in general would like to never balance bill,” he said. “But if it’s an unreasonable payment the insurance companies come up with, the doctors have no choice.”

For the majority of Californians whose health plans are regulated by DMHC, balance billing for emergency services is not allowed, said the agency’s Marta Green.

“Any dispute over payment is between the provider and the plan, and the enrollee cannot be placed in the middle,” she said.

But it’s still possible to receive an incorrect bill even if you have a plan regulated by DMHC, like I did. Your plan may, for instance, argue that you weren’t really having an emergency and that you didn’t need to seek out-of-network emergency care.

So here’s some advice:

•  Know which hospitals are covered by your plan and go to a network provider if you can. “That will be the safest thing for financial risk,” Sugarman said.

•  If you receive a bill from a provider for out-of-network emergency services that you believe is incorrect, dispute it with your insurer. If that doesn’t resolve the problem, file a formal appeal with your insurer.

•  If you’re still stuck, call CDI’s hotline (number above) or DMHC’s Help Center at (888) 466-2219.

My final suggestion is to call or email your state legislators and ask them to change the law so that all Californians have the same protection against balance billing.

From Emily Bazar of the OC Register-

What good is it to have a health plan if you can’t find doctors and hospitals to accept it?

That question rushes to mind every time a frustrated reader writes in to describe his or her Kafkaesque quest to find care.

I’m also hearing from frustrated medical providers, including Dr. Nelson Branco, a pediatrician in Marin County Branco was one of more than 2,300 California doctors who participated in a survey conducted by the California Medical Association (CMA) in April.

The survey found that 80 percent of those who responded were, at some point, confused about their participation in health plans sold by Covered California, the state’s health insurance exchange.

That was “at some point.” Right now? One in five doctors remains confused.

Poor consumers! What chance do you have to find a doctor in your network if doctors themselves don’t know?

In today’s column, I’m sorry to have to describe yet another pitfall that could complicate your ability to receive care from a doctor who participates in your health plan.

Q: I bought a Blue Shield plan, which my physician is on. But the only hospital where my doctor has privileges is not contracted with Blue Shield. Is this problematic?

As a matter of fact, yes.

Let’s say you need surgery. Your doctor, who is in your network, plans to perform the procedure at a nearby hospital, the only hospital where she has privileges.

You do a little homework (because that’s what you have to do in this new insurance environment), and you discover that the hospital isn’t in your plan’s network.

Uh-oh.

As more Californians start to use their new health insurance, they’re finding these kinds of doctor and hospital mismatches: Sure, there may be hospitals in your network. But they’re not necessarily the ones to which your physician can admit patients.

These mismatches often are a result of newly created “narrow networks” that have limited doctor and hospital choices for plans bought through Covered California or on the private market. These networks were created by some health insurance plans to save money: Insurers pay fewer providers lower fees but promise them higher volumes of patients in return.

(Not that networks were unlimited before. But now, some are substantially smaller.)

In Marin County, when children need urgent care in the evening or on weekends, the county’s pediatricians refer them to a specific after-hours clinic, Branco says.

But Branco’s patients who purchased an Anthem Blue Cross plan through Covered California can’t get in-network coverage at the clinic. Even though Branco contracts with Anthem, the clinic does not.

Faced with the prospect of paying out of pocket, some parents simply take their children to the emergency room, a much more costly form of health care, he says. (And one that defeats two major goals of Obamacare: Reducing unnecessary care and lowering costs.)

“It’s really a mess,” the pediatrician says. “The after-hours clinic has kept thousands of patients out of the ER and saved thousands of untold ER dollars. Now, to limit access to the after-hours clinic is really just shooting ourselves in the foot.”

Hospitals are complaining about mismatches, too, says Dietmar Grellmann of the California Hospital Association.

“If a health plan throws networks together and doesn’t take the time to sort through the physician admitting relationships (with hospitals), you get these kind of mismatches,” he says.

Lindy Wagner of Blue Shield of California says mismatches shouldn’t occur because the networks “were designed to include physicians with admitting privileges to hospitals in the network.”

Blue Shield is working with doctors to clear up confusion about their participation in plans and is continually adding doctors to its network, she says.

That’s all great. But it is happening.

What are consumers to do now?

The most critical time to do your homework on networks is before you buy a plan, Grellmann says.

“When consumers sign up for Covered California, they really need to do some due diligence, not just shop for the cheapest product,” he says. “The days of signing up for a plan and expecting everything to go great are probably over.”

Grellmann acknowledges that confusion and misinformation reigned during open enrollment and that it was very difficult for consumers to decipher networks at that time.

So now that you’re stuck with a plan, the best thing you can do is verify, verify, verify.

Confirm not only that your doctor is in network, but the hospital, too. Check your information against multiple sources, including your insurer.

And get nosy.

“It may be worth asking your doctor if they have privileges at a network hospital,” says Brett Johnson of the CMA.

If you learn that the hospital or hospitals where your doctor has privileges are NOT in your network, you likely face an unpleasant reality (assuming you don’t want to be out tens of thousands of dollars for going out of network): Switching doctors.

“They’re going to have to make a choice that, from the patient’s perspective, is probably not a good choice,” Grellmann says.