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Dental Insurance
Information
While the roles you and your dentist play in
maintaining your oral health are easy to understand, the role of dental
benefits is sometimes unclear. Insurance industry jargon used to describe
your benefits often blurs the actual terms of coverage. With this in mind,
we've provided an insurance 'cheat sheet' to aid you in getting the most out
of your coverage. If you should have a question concerning your insurance
coverage, contact your dental insurance provider or just ask during your
next visit to one of our offices.
Exactly What Does That Mean...
Understanding the UCR
UCR: A widely used method, which may
vary from company to company, for determining benefit reimbursement levels.
The initials simply mean:
Usual: The fee that an individual
dentist most frequently charges for a given dental service.
Customary: A fee determined by the
insurance company based on the range of usual fees charged by dentists in
the same geographical area.
Reasonable: A fee which is
justifiable considering special circumstances of the particular care
rendered.
Other
Terms
Table of Allowances: Assigns a
specific dollar to each dental procedure.
Pre-determination: After the
treatment plan is decided upon by the patient and the dentist, the insurance
company reports back on what portion of the treatment plan will be covered.
Freedom of Choice: Allows the patient
to choose any dentist. Coverage with this feature allows you to receive full
benefits for treatment provided by any dentist of your choice.
Limitations: Limits the benefits for
procedures or the number of times a procedure will be covered.
Exclusions: Denies benefit coverage
for certain procedures.
Least Expensive Alternative Treatment: The insurance
company's contractual arrangement with the policyholder allows the insurance
company to substitute a less expensive, but in the insurance company's
opinion, professionally adequate service.
How Well Do You
Know Your Benefits?
 1.
What types of dental coverage are offered by your employer or union?
2.
Which procedures does your dental plan limit or exclude? Do certain
procedures have waiting periods?
3.
How are your benefits calculated? (UCR? Table of Allowances?)
4.
Does your plan allow pre-determination of benefits?
5. Does
your plan impose an annual maximum benefit level?
6. What
are your co-payments?
7.
Does your policy cover only the least expensive alternative treatment?
Tips On Getting
The Most From Your Dental Plan
1.
Read your benefits booklet. Dental health coverage is provided by your
employer or union to help you handle the costs of staying healthy. Using
them wisely is your responsibility.
2.
Know your options. Be familiar with the exclusions and limitations of your
coverage.
3.
Communicate with your dentist, employer, and insurance company. Keep
everyone informed of your experiences.
4.
Practice good oral hygiene. Follow the hygiene habits prescribed by your
dentist.
5.
Ask questions. Be a partner in your own dental health.
Commonly Asked
Questions and Answers
Q1: Why does my dental insurance pay only 50% of the
charges when my policy says it will pay 80%?
A1: There are several possibilities:
1. If your benefits are based on UCR calculation, it might indicate that
the UCR data is out of date or not specific to your local area.
2. If you belong to a PPO, your full benefits will be paid only if you
seek care from one of the contracting dentists.
3. If your benefits are calculated using a Table of Allowances, the
table might be out of date or set at an unrealistically low amount.
4. If your policy provides for the least expensive treatment, you will
be reimbursed the stated percentage based on the cost, even if you
choose alternative treatment.
Q2: Why can't I go to any dentist?
A2: Many employers will contract with a closed
panel or preferred provider program to contain the costs of insuring
employees. As a result, your dental benefits might only be available by
seeking care from a dentist who has contracted with that company.
Q3: Why do my premiums keep going up?
A3: Dental insurance premiums are in part based on
the anticipated claims experience of your group. If that group
experiences an unexpected high utilization of major dental services, the
premiums will go up. Insurance company administrative costs and premium
taxes also contribute to the cost of dental coverage.
Q4: Is my dentist overcharging when my insurance
company reimburses me for only part of the dental fees?
A4: No. Insurance companies pay claims in various
ways. Many base reimbursements on UCR rates. However, even the UCR
allowance may vary from company to company. While these reimbursements
usually are based on what the majority of dentists in your area charge,
sometimes the figures used to calculate benefits may be out of date or
not specific to your location. And, if the company uses a Table of
Allowances, benefits assigned to specific dental treatment may not
relate to actual costs.
What Does Your
Dental Benefit Plan Do For You?
Dental
benefit plans help you pay for certain kinds of dental care. Your dental
health care decisions should take into account more than just what is
covered. Your dental health needs can only be determined by you through
consultation with your personal dentist. Good dental care is your right, and
can best be attained by understanding your specific dental needs and how
your dental benefits plan relates to them.
What Type of
Plan Do You Have, Need, or Want?
Indemnity: Indemnity benefits are
expressed as a covered fee-for-service. This coverage allows patients to
choose their own dentist. Limits and co-payments are set according to the
level of coverage purchased by the employer or union.
Direct Reimbursement: Enables
employers to offer cost-effective dental benefits while allowing employees
the freedom to choose their own dentists. The patient receives prescribed
dental treatment and is reimbursed directly by the employer.
Self Insurance: The employer assumes
the role of an insuring agency.
Dental Care Service Plan: A
non-profit organization of participating dentists who agree to charge
enrolled patients fees which do not exceed a predetermined level.
Closed Panel: Offers a limited number
of facilities and a limited number of dentists from whom care must be
obtained.
Capitation Plan: You're assigned to a specific dental
office where contracting dentists receive a fixed monthly fee per patient
regardless of whether treatment is performed.
Preferred Provider Organization (PPO):
A group of dentists who contract with an insurance company to provide care
at discount fees. ("Preferred" refers to a dentist who has contractually
agreed to provide services at discounted fees.)
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