Have Dental Insurance? It may not be as good as you think! Read your manuals and all the fine print.
Dental insurance was NOT designed to cover the total cost of treatment. Dental benefits are not insurance in the traditional sense as with medical insurance but are designed to provide you with some assistance in paying for your dental care. A plan may have limitations on the number of visits, consultations, radiographs (x-rays) and various treatments it will cover.
Know your insurance benefits – they’re not always what they are portrayed.
As a courtesy to our patients, we file all dental insurance claims electronically. We file claims to any insurance carrier, however, we do remind you that your policy is an agreement exclusively between you and your employer. We can make no guarantee of estimated coverage but do our best to see that you receive your maximum benefits.
Commonly Misunderstood Dental Plan Terms and Features
Usual, Customary & Reasonable
“Usual, Customary and Reasonable” – UCR as insurances refer to it – may be one of the most misunderstood terms used in describing dental benefit plans. UCR plans may pay an established percentage of the dentist’s fee, or what the plan considers a “customary” or “reasonable” fee limit, whichever is less.
Although these limits are called “customary,” they may or may not reflect the actual fees that dentists in your area charge. Your explanation of benefits (EOB) may note that the fee your dentist has charged you is higher than the UCR reimbursement levels that the plan offers. This does not mean that you have been overcharged. For example, the benefits company may not have taken into account up-to-date data in determining a reimbursement level. What we, in the dental field have questioned is – if the UCR is determined by areas – then why isn’t the reimbursement rate for our area the same for every insurance? It’s NOT! There is NO regulation as to how insurance companies determine reimbursement levels, and companies are not required to disclose how they determine these levels. This results in wide fluctuations.
Least Expensive Alternative Treatment Provisions
Your dental plan may not allow benefits for all treatment options, even when your dentist determines that a specific treatment is in your best interest. For example, your dentist may recommend a crown, but your plan may only offer reimbursement for a large filling. As with other choices in life, such as purchasing medical or automobile insurance or buying a home, the least expensive alternative is not always the best option.
Your dental benefits plan purchaser (usually your employer) makes the final decision on “maximum levels” of reimbursement through its contract with the insurance company. The annual maximum often is based on the amount the employer wishes to pay for the dental benefit. Even though the cost of dental care has increased significantly over the years, the maximum levels of reimbursement have not changed much in 30 years.
In a preferred provider arrangement, you may be asked to choose your dentist from a list of the plan’s preferred providers. These are dentists who discount their fees in return for being listed as practitioners who participate in the benefit plan’s network of providers. Whether or not you choose your dental care provider from this defined group can affect your reimbursement.
Pre-Existing Conditions & Exclusions
Just as with medical insurance, a dental plan may not cover conditions a person had before enrolling in the plan. Even though your plan may not cover certain conditions, treatment may be necessary. Your dental plan may not cover certain procedures or preventive treatments regardless of their value to you. This does not mean these treatments are unnecessary.
The employer uses these “exclusions” to save premium expense. A policy might be written with no benefits for bridges, which are used to replace missing teeth, or no benefit for periodontal (gum) treatment. These exclusions have nothing to do with the dental needs of the patient. It doesn’t matter how badly the patient may need the treatment; if it’s not in the contract, it’s not covered. It’s tempting for patients to say they only want the treatment that’s covered by their insurance. However, it’s important to understand that the insurance plan was not written with any patient’s best interest in mind. Limiting treatment to what the insurance covers may be hazardous to your health.
Insurance In Our Office
Our professional treatment is rendered to you based on your needs. The amount of the benefits to be derived from your insurance policy is a contractual agreement between your employer/self and the insurance company. In other words, the benefits under your insurance plan are limited by the specifics of the contract between the insurance company and your employer/self. We have access to some information about most plans and can give you an estimate of your plan’s benefits. If you have any questions regarding reasons behind limitations and exclusions, you should refer these to your employer.
Some plans request a pre-determination of benefits prior to beginning a course of treatment. This is ONLY a request and is NOT mandatory. The reason they suggest a pre-determination is so you can see what your out-of-pocket expenses will be. As a matter of fact on every pre-determination, there is a statement written clarifying that “it is in no way a guarantee of payment.” Regardless, we will be happy to submit the appropriate forms to your insurance company. There is usually a 3 to 6 week turn around time for these forms.
We will provide all the assistance we can and do our best to see that you receive your full benefits within the structure of your particular plan.
QUESTIONS? Ask your Plan Sponsor
Our team will do our best to answer your insurance questions but cannot always answer specific questions about your dental benefits or predict the level of coverage for a particular procedure. Plans written by the same benefits company or offered by the same employer may vary according to the contracts involved. Your plan sponsor (usually your employer) is usually in the best position to explain the individual features of your plan and may answer specific questions about your coverage.
Frequently Asked Questions
Q. My dentist recommends a treatment that my plan will not pay for. Does this mean the treatment really isn’t necessary?
A. It is common for dental plans to exclude treatment that is covered under the company’s medical plan. Some plans, however, go on to exclude or discourage necessary dental treatment such as sealants, pre-existing conditions, adult orthodontics, specialist referrals and other dental needs. Some also exclude treatment for family members. Patients need to be aware of the exclusions and limitations in their dental plan but should not let those factors determine their treatment decisions.
Q. My dentist recommends that I get a crown on a tooth, but my dental benefit will only pay for a large filling for that tooth. Which treatment should I have?
A. Some plans will only provide the level of benefit allowed for the least expensive way to treat a dental need, regardless of the decision made by you and your dentist as to the best treatment. Sometimes, special circumstances may be explained to the third-party payer to request an adjustment to this lower benefit allowance, but there is no guarantee that the third-party payer will alter its coverage. As in the case of exclusions, patients should base treatment decisions on their dental needs, not on their dental benefit plan.
Q. My dental plan says that it will pay 100 percent for two dental checkups and cleanings each year. However, I just had my first checkup and cleaning, and now the insurance company says I owe for part of the dentist’s charge. How can this be?
A. Plans that describe benefits in terms of percentages, for example, 100 percent for preventive care or 80 percent for restorative care, are generally Usual, Customary and Reasonable (UCR) plans. As explained in the section in this page on “How Benefits are Determined,” the administrators of URC plans set what the plan considers to be a “customary fee” for each dental procedure. If your dentist’s fee exceeds this customary fee, your benefit will be based on a percentage of the customary fee instead of your dentist’s fee. Exceeding the plan’s customary fee does not mean your dentist has overcharged for the procedure. As a matter of fact if there is UCR (usual, customary and reasonable) for specific areas/zip codes, then why isn’t the UCR fee covered by each insurance company the same?
Q. Will my plan cover the care my family will need?
A. This should be a prime consideration and a major motivation in choosing one plan over another. If your employer offers more than one plan, look at the exclusions and limitations of the coverage as well as the general categories of benefits. You should discuss your family’s current and future dental needs with your family dentist before making a final decision on your dental plan.
Q. Who is covered by my dental benefit plan? What does my dental plan cover?
A. This information should be provided by the plan purchaser, often your employer or union, and by the third-party payers in order for you and your dentist to be aware of the benefits provided by a dental benefit plan, the extent of any benefits available under the plan should be clearly defined, limitations or exclusions described, and the application of deductibles, copayments, and coinsurance factors explained to you. This should be communicated in advance of treatment. The plan document should describe the benefit levels of the plan and list any exclusions or limitations to that coverage. This document should also specify who is eligible for coverage under the plan and when that coverage is in effect. Your dentist cannot answer specific questions about your dental benefit or predict what your level of coverage for a particular procedure will be. This is because plans written by the same third-party payer or offered by the same employer may vary according to the contracts involved. Therefore, you should ask the plan purchaser or the third-party payer to answer your specific questions about coverage.
Q. My spouse and I each have a dental benefit plan. Whose program covers whom? Can we decide whose program covers our children?
A. Your program covers you. Your spouse’s program covers him or her. You may have additional coverage from each other’s programs if they cover spouses and dependents. In no case should the benefit derive from the two coordinated programs exceed 100 percent of the dentist’s charges for treatment. The primary plan for covering your children depends on the regulations in your state. Most plans use the “birthday rule” (spouse with birthday occurring earlier in the calendar year is primary). Others consider the father’s plan primary. The American Dental Association has recognized the “birthday rule” as the preferred method for coordinating benefits, but which rule applies to your family depends on the language in your dental plan documents. If you have two or more potential sources of coverage, check the coordination of benefits language for each plan to determine the benefits available.
Q. Does my dentist have to send a description of my treatment plan to the third-party payer before I have any dental work done?
A. Third-party payers often request a “predetermination of benefits” on certain treatment plans. Usually, this means a dental consultant will review your dentist’s treatment plan and determine what benefits your plan will provide. But this predetermination is not a guarantee of payment. You may want to review your benefit prior to receiving treatment, but the final treatment decision should be a matter between you and your dentist, regardless of your benefit.
There may be a provision in your plan that will deny your normal dental benefit, or reduce the level of coverage if you do not submit the treatment plan for prior authorization. This is a contractual matter between the plan purchaser and the plan administrator and is contrary to the policy of the American Dental Association. The American Dental Association is opposed to any dental clause that would deny or reduce payment to the beneficiary, to which he/she is normally entitled, solely on the basis or lack of pre-authorization.
If You Do Not Currently Have A Dental Benefit, You May Want To Know…
Q. I do not have a dental benefit and need some major dental work. Where can I buy individual dental insurance?
A. Dental plan coverage for individuals is not commonly offered because dental needs are highly predictable. For example, you would not pay premiums for your dental coverage if the premiums were more expensive than the cost of the dental treatment you need. Since this is the case, insurance companies would stand to lose money (spend more on benefits than they receive in premiums) on every individual dental plan they write. There are, however, a few companies that offer a form of dental benefits for individuals. Most of these plans are “referral plans” or “buyers’ clubs.” Under these types of plans, an individual pays a monthly fee to a third party in return for access to a list of dentists who have agreed to a reduced fee schedule.
Payment for treatment is made from the patient directly to the dentist. The third party acts only in the capacity of matching the individual to the dentist. The dentist receives no payment from the third party other than in the form of referral of patients.
Q. I would like to ask my employer to provide a dental benefit plan through the company. How should I go about doing this?
A. The American Dental Association recognizes the important role dental benefits have played in improving access to dental care for millions of Americans. You or your employer may contact the Association for more detailed information about how employers of all sizes can provide a cost-effective, high-quality dental benefit plan for their employees.
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