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Understanding your dental benefits is not easy. There are as many different plans as there are contracts. Your employer has selected your plan and is ultimately responsible for how your contract is designed. Remember, whether your plan covers a major portion of your dental bill, or only a small amount, dental benefits are good for patients because they help pay for needed treatment.
It is important to know that each contract will specify what types of procedures are considered for benefits. Even if a procedure is medically and dentally necessary, it may be excluded from your contract. This does not mean that you do not need the procedure. It simply means that your plan will not consider the procedure for payment. For example, cosmetic procedures and implants are often excluded from a dental plan.
It is a mistake to let benefits be your sole consideration when you determine what you want to do about your dental condition. The following is provided to you to answer a few common patient questions:
Why doesn’t my insurance cover all the costs for my dental treatment?
Dental insurance isn’t really insurance (a payment to cover the cost of a loss) at all. It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment. The employer usually buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost.
But my plan says that my exams and certain other procedures are covered 100%.
That 100% is usually what the insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge. For example, say your dentist charges $80 for an examination (not counting x-rays). Your carrier allows $60 as the 100% payment for that examination, leaving $20 for you to pay.
If my plan does not really cover any procedures at 100% why does it say it will?
Benefit plan booklets are often difficult to understand. If any part of your plan is not clear to you or if you think something is wrong concerning what your plan covers, you should contact your Employer Benefits Coordinator or the Human Resource department where you work.
How does my insurance carrier come up with its allowed payments?
Many carriers refer to their allowed payments as UCR, which stands for usual, customary and reasonable. However, UCR does not really mean exactly what it seems to mean. UCR is actually a listing of payments for all covered and procedures negotiated by your employer and the insurance company. This listing is related to the cost of the premiums and where you are located in your city and state. Your employer has likely selected an allowed payment or UCR payment that corresponds to the premium cost they desire. UCR payments could be more accurately called negotiated payments.
Since the payments are negotiated, does this mean that there is always a balance left for me to pay?
Typically there is always a portion that is not covered by your benefit plan.
If I always have a balance to pay, what good is my insurance?
Even a benefit plan that does not cover a large portion of the cost of needed dentistry pays something. Any amount covered reduces what you have to pay out of pocket. It helps!
I received an Explanation of Benefits from my insurance carrier that says my dental bill exceeded the usual and customary. Does this mean that my dentist is charging more than he/she should?
Remember that what insurance carriers call usual and customary is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment. It is usually less and frequently much less than what any dentist in your area might actually charge for a dental procedure. It does not mean that your dentist is charging too much.
Why is there an annual maximum on my benefits?
Maximums limit what a carrier has to cover each year. Amazingly, despite the fact that costs have steadily increased, annual maximum benefit levels for dental care have not changed since the 1960s.
Why do some benefit plans require me to select a dentist from a list?
Usually the dentists on the list have agreed to a contract with the benefit plan. These contracts have restrictions and requirements. If you choose a dentist on the list, you typically will pay less toward your dental care than if you choose a dentist not on the list. If your dentist is not on the list this does not mean that something is wrong with the dentist or the office.
Why does my benefit plan only pay toward the least expensive alternative treatment?
To save money, many dental plans allow a benefit only for the least expensive method of treatment. For example, your dentist may recommend a crown with your insurance only offering a benefit towards a filling. This does not mean that you have to accept the filling. The good news is that some benefit will be paid; the bad news is that more of the fee will be your responsibility. Remember that your dentist’s responsibility is to prescribe what is best for you. The insurance carrier’s responsibility is to control payments.
Why won’t my insurance pay anything toward some procedures, such as x-rays, cleanings, and gum treatments?
Your plan contract specifies how many of certain types of procedures it will consider annually. It limits the number of x-rays, cleanings, and gum treatments it will cover because these are the types of treatments that many people need to have frequently.
I know that my insurance plan doesn’t go into effect until next month. Why won’t my dentist do my treatment today, but send in the claim next month so that the insurance will pay?
State laws regulate these issues. It is insurance fraud to change dates of service on a claim. Both the patient and the dentist can be prosecuted.
Why doesn’t my dentist participate in my dental benefits network plan?
Some plans require that the network dentists observe restrictions to treatment. Many dentists are not comfortable with this.
What should I do if my insurance doesn’t pay for treatment I think should be covered?
Because your insurance coverage is between you, your employer, and the insurance carrier, your dentist does not have the power to make your plan pay. If your insurance doesn’t pay, you are responsible for the total cost of treatment. Sometimes a plan may pay if patients send in claims themselves. The Employee Benefits Coordinator at your place of business also may be able to help. Consumers (patients) may also lodge complaints with the State Insurance Commission.