Deciphering Your Dental Insurance
Deciphering Dental Insurance
Understanding Your Insurance
If your employer offers dental insurance, consider yourself fortunate. This benefit works like a valuable “coupon” that can greatly reduce the costs of dental care. However, no dental benefit plan is set up to cover all of your costs. To avoid surprises on your dental bill, it is important to understand what your insurance will cover, and what you will need to cover some other way. Dental benefits should not be confused with the dental services you need, which are determined by you and your dentist.
How dental plans work
Almost all dental plans are the result of a contract between your employer and an insurance company. The amount your plan pays is agreed upon by your employer with the insurer. Your dental coverage is not based on what you need or what your dentist recommends. It is based on how much your employer pays into the plan. Employers generally choose to cover some, but not all, of employees’ dental costs. If you are not satisfied with the coverage provided by your insurance, let your employer know.
The role of your dental office
Your dentist’s main goal is to help you take good care of your teeth. Many offices will file claims with your insurance company as a service to you. The portion of the bill not covered by insurance is your responsibility. Many practices offer financing plans or other ways to help you pay your part of the bill.
Key terms used to describe the features of a dental plan may include the following:
UCR (Usual, Customary, and Reasonable)
Usual, customary and reasonable charges (UCR) are the maximum amounts that will be covered by the plan. Although these terms make it sound like a UCR charge is a kind of standard rate for dental care, that is not the case. The terms “usual,” “customary” and “reasonable” are misleading for several reasons:
• UCR charges often do not reflect what dentists “usually” charge in a given area.
• Insurance companies can set whatever they want for UCR charges–they are not required to match actual fees charged by dentists.
• A company’s UCR amounts may stay the same for many years–they do not have to keep up with inflation, for example.
• Insurance companies are not required to say how they set their UCR rates. Each company has its own formula.
So if your dental bill is higher than the UCR, it does not mean your dentist has charged too much for the procedure. It could mean your insurance company has not updated its UCRs, or the data used to set the UCRs is taken from areas of your state that are not similar to your community.
This is the largest dollar amount a dental plan will pay during the year. Your employer makes the final decision on maximum levels of payment through the contract with the insurance company. You are expected to pay copayments, as well as any costs above the annual maximum. Annual maximums are not always updated to keep up with the costs of dental care. If the annual maximum of your plan is too low to meet your needs, ask your employer to look into plans with higher annual maximums.
The plan may want you to choose dental care from a list of its preferred providers (dentists who have a contract with the dental benefit plan). The term “preferred” has nothing to do with the patient’s personal choice of a dentist; it refers to the insurance company’s choices. If you choose to receive dental care from outside the preferred provider group, you may have higher out-of-pocket costs. Inform yourself about your plan’s methods for paying both in- and out-of-network dentists.
A dental plan may not cover conditions that existed before you enrolled in the plan. For example, benefits will not be paid for replacing a tooth that was missing before the effective date of coverage. Even though your plan may not cover certain conditions, treatment may still be necessary to maintain your oral health.
Coordination of Benefits (COB) or Nonduplication of Benefits
These terms apply to patients covered by more than one dental plan (for example, if you are insured by your employer and are also on your spouse’s plan). Insurance companies usually want to know if you have coverage from other companies as well, so they can coordinate your benefits. For example, if your primary (main) insurance will pay half your bill, your secondary insurance will not cover that same portion of the bill.
Benefits from all companies should not add up to more than the total charges. Even though you may have two or more dental benefit plans, there is no guarantee that all of the plans will pay for your services. Sometimes, none of the plans will pay for the services you need. Each insurance company handles COB in its own way. Please check your plans for details.
A dental plan may limit the number of times it will pay for a certain treatment. But some patients may need treatment more often than that for best oral health. For example: a plan might pay for teeth cleaning only twice a year even though the patient needs cleaning four times a year. Be aware of the details in your dental plan but decide about treatment based on what’s best for your health, not just what may be covered.
Not Dentally Necessary
Each dental benefit plan has its own guidelines for which treatment is “dentally necessary.” If a service provided by your dentist does not meet the plan’s “dentally necessary” guidelines, the charges may not be reimbursed.
However, that does not mean that the dental treatment was not necessary. Your dentist’s advice is based on his or her professional opinion of your case. Your plan’s guidelines are not based on your specific case. If your plan rejects a claim because a service was “not dentally necessary,” you can follow the appeals process by working with your benefits manager and/or the plan’s customer service department.
Least Expensive Alternative Treatment (LEAT)
If a plan has a LEAT clause, it means that if there is more than one way to treat a condition, the plan will only pay for the least expensive treatment. This is one way that insurance companies keep their costs down. However, the least expensive alternative is not always the best option. You should consult with your own dentist on the best treatment option for you.
Explanation of Benefits (EOB)
An EOB is a written statement from the insurance company, telling you what they will cover and what you must pay yourself. Your portion of the bill should be paid to the dental practice. If you have questions about the EOB, contact your insurance provider.
Make your dental health the top priority
Although you may be tempted to decide on your dental care based on what insurance will pay, always remember that your health is the most important thing. As with other choices in life–such as buying medical or auto insurance, or even a home–the least expensive option is not always the best.
Now you know more about “Why doesn’t my insurance pay for this?” Your employer has agreed with the insurance company to pay for part of your treatment through your dental insurance plan. While it can be frustrating if you expect insurance to cover the whole bill, the costs of dental care can be managed. Just get familiar with your dental coverage and do some advance planning. Work with your dentist to take the best possible care of your teeth so they will last a lifetime!
Patient education content ©2013 American Dental Association. All rights reserved. “ADA” and the “ADA” Logo are registered trademarks of the American Dental Association.