The Purpose of Dental Plans
Its main purpose is to help individuals by paying for
a portion of the cost of their dental care.
Almost all dental benefit plans are the result of a
contract between an employer and an insurance company. For this reason, concerns
about your dental plan should first be directed to your plan sponsor.
Limitations in coverage are the result of the
financial commitment your employer has agreed to make and the
benefits the insurance company will offer in exchange for that
Treatment decisions must be made by you and your
dentist. While dental benefit coverage should be taken into
account, it should not be the deciding factor in your choice of
How Benefits Are Determined
You should know how your plan is designed, since this
can affect significantly the plan's coverage and your out-of-pocket
To understand and make decisions about your
dental benefits, it is important to remember that plans are often very
different. To make the best decision for you and your family, you should
understand exactly how the different kinds of dental benefit plans work
and how they derive their cost savings.
common designs can be grouped into the following categories:
Your dental plan is
designed to SHARE
in your dental care costs. It may not cover the total cost of your
bill. Most plans cover between 50-80% of dental services.
Treatment may be offered
that your plan will
not pay for. Does this mean the treatment really isn't necessary? Some
plans exclude or discourage necessary dental treatment such as
sealants, pre-existing conditions, adult orthodontics, specialist
referrals and other dental needs. Some also exclude treatment by family
members. Do not let those factors determine your treatment decisions.
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.
UCR: A widely used method, which may vary from company to
company, for determining benefit reimbursement levels. The initials
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 geographic area.
Reasonable. A fee which is justifiable considering special
circumstances of the particular care rendered.
Table of Allowances: Assigns a specific dollar to each dental
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 Alternate 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.
to know your Benefits:
1. What types of dental coverage are offered by your employer or
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 alternate
1. Read your benefits booklet. Dental health coverage is provided
by your employer 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.
Dental benefit plans help you pay
for certain kinds of dental care.
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.
The fee charged is never
changed from patient to patient depending on what their
coverage will pay. Furthermore, our fees are set to allow us to continue to
provide the highest of quality of care, service and value to our
patients. We feel that this is the only ethical way to do business and
we will never compromise those values. Please do not embarrass us by
asking us to do so.
Source: American Dental Association