Having dental insurance is a great benefit that makes it easier to get the dental care you need. Dental insurance can be complex because every insurance company and every plan is different. Dental plans are designed to share the cost of your dental treatment, not to completely pay for the cost of dental treatment. Most dental plans do not cover all dental procedures. It is important to make your decisions about dental care based on your needs and doctor’s recommendations, not just what your insurance will pay. Work with your dental office to get the best care while maximizing your dental benefits.
Most dental plans are a contract between your employer and the insurance company. The employer has a contract with the insurance company that will determine what services will be covered and the maximum benefit amount allowed for each service. All plans also have frequency limitations which restrict the number of times certain procedures are available during a given time period. The contract also stipulates the maximum annual benefit – the amount a dental plan will pay towards treatment during the contract year. The insurance company establishes a UCR fee (usual, customary & reasonable) for each dental procedure. Each company has their own formula for setting a UCR fee and they can set whatever amount they want. The UCR fee is not the same for each company or plan within one insurance company. The UCR fee does not have to keep up with the actual cost of dental care or inflation and it does not coincide with the dentist’s fee. If your dental fees are higher than the UCR fee, it does not mean your dentist has overcharged you.
Also check your plan for a “Pre-Existing Condition” clause, which means they may not cover a condition that existed before you enrolled in the plan. For example, if you want to replace a tooth that was missing pre-enrollment, they would deny treatment for that replacement. “Bundling” is sometimes used to group two separate procedures into one procedure or “Down-Coding”, when they change the procedure code to a less complex or lower cost procedure than what was reported by the dental office. “Least Expensive Alternative Treatment” (LEAT) means there is more than one way to treat a condition; the plan will pay for the least expensive option, even if the least expensive option is not the best treatment for you.
Some plans may require you to choose dental care from a dentist in its network of preferred providers. Preferred means these dentists have a contract with the insurance company. It does not mean these are dentists preferred by their patients.
These are a few examples of some of the more prevalent situations regarding insurance language. It is highly recommended you educate yourself on your dental insurance plan so you know what to expect in benefits. Our dental office will work with you to help you understand how your insurance works to maximize your insurance benefit and to get the dental care you need.