Having dental insurance or a dental benefit plan can make affording needed dental care much easier. However, most dental benefit plans do not cover all necessary dental procedures. It is important for patients to understand their dental plans, and covered benefits are not designed around what treatment their dentist recommends or what services that specific patient needs. An individual’s coverage is based on how much their employer pays into the plan. When considering dental treatment, insurance coverage and dental benefits should not be the only consideration. Treatment should be determined by the patient, their dentist, and the patient’s specific dental needs.
How Dental Plans Work
Most commonly, dental plans are a contract between your employer and an insurance company. The chosen insurance company and employer agree on the amount your plan will pay and what procedures are covered. Often, you may have dental care needs not covered by your plan. Covered services are based on the dental plan you have.
Being a healthcare provider first and foremost, your dentist’s top priority is your oral health and aiding you in taking care of your teeth. Our office will file claims to your dental plan as a courtesy to you. The amount of the bill for whatever reason not covered by insurance is your responsibility.
To help you understand your coverage and benefits listed are some key terms used when discussing the features of a dental benefit plan.
Annual Maximums
This is the largest dollar amount a dental plan will pay during the year. You are expected to pay any costs higher than the annual maximum as well as any copayments. Most dental plans run on a calendar year (Jan-December) and benefits renew January 1st. However some plans run on a benefit year and the dates of benefit renewal vary. It is important to check with your insurance company to see when your benefits renew. It is also important to know that annual maximums are not always updated to keep up with costs of dental treatment. If you feel your annual maximum is too low please consult your employer and or dental insurance company.
UCR (Usual, Customary, and Reasonable) Charges
UCRs are the maximum allowable amount that will be covered by your plan for a specific service/s. The term UCR makes it sound as if this is the standard rate for dental care, however it is not and the use of these terms can be very misleading. First, insurance companies determine the charges for UCR’s and can pick whatever amount they want. The amount they choose often does not coincide with what actual dentists in the area charge for specific procedures. Secondly, UCR rates may stay the same for years, meaning they do not have to keep up with things like inflation or be reflective of actual costs of dental treatment. Lastly, insurance companies do not have to explain how they set their UCRs and the formula used by each company varies. If your bill is larger than the UCR set by your insurance plan it does not mean your provider has overcharged you.
Preferred Providers
Your insurance plan may want you to seek treatment from a provider in its preferred network. The term preferred means these dentists are contracted with the insurance plan. It does not mean these are providers the patient prefers.
Pre-Existing Condition
Some dental plans do not cover conditions that existed prior to the patient being enrolled. For example, your insurance may not cover benefits for replacing a missing tooth if the tooth was gone before the effective coverage date. Despite your plan not paying for specific conditions, you may still need treatment to maintain optimum oral health.
Unfortunately many patients make decisions about their dental care solely based on their insurance coverage. When making decisions about your dental care it is crucial to remember your health is priority number one. Work with your dentist so your teeth with last a lifetime.
Two of the most common misassumptions by patients is first, that their dental insurance covers all dental procedures (codes) and secondly that their dental plan will cover the entire cost of a specific procedure or treatment.