The facts to help you understand your dental insurance options
No insurance plan covers all dental expenses. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is the patient’s responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by their insurance company.
Insurance companies are in business to make money. They make more profit by paying fewer benefits. They also profit more by waiting to pay claims and by making dentists send in pre-estimates on the more expensive procedures. Delays in treatment results in less treatment.
Dental insurances design their policies as such to cover the preventive treatment at a maximum level and cover for the “major” dental work at a minimal cost for themselves. Also, if you are working for an organization, some dental insurances work with your employer to come up with a dental plan. What is covered or not covered is decided by your empolyer and the benefit you choose to purchase and not by the dentist.
WHY DOESN’T MY INSURANCE PAY FOR THIS?
UCR (Usual, customary and reasonable):
Under a UCR plan, patients are usually allowed to see the dentist of their choice. These plans pay an established percentage of the dentist’s fee or pay the plan sponsor’s “customary” or “reasonable” fee limit, whichever is less. Although these limits are called “customary,” they may or may not reflect the fees that area dentists charge.
It may also be noted on your bill the fee that your dentist has charged you is higher than the reimbursement levels of UCR. This does not mean your dentist is overcharging you. For example, the insurance company may not have taken into account up-to-date, regional data in determining a reimbursement level.
WHY? There is no regulation as to how insurance companies determine reimbursement levels, resulting in wide fluctuation. In addition, insurance companies are not required to disclose how they determine these levels. The language used in this process may be inconsistent among carriers and difficult to understand.
Your plan purchaser makes the final decisions on “maximum levels” of reimbursement through the contract with the insurance company.
Even though the cost of dental care has significantly increased over the years, the maximum levels of insurance reimbursements have remained the same since the late 1960’s. Many plans offer higher maximums that are comparable to rising dental care costs.
Your plan may want you to choose your dental care from a list of their preferred providers. Whether or not you choose your dental care from this defined group can affect your levels of reimbursement. If you have a PPO plan, it is your “right” to choose whom to go to. However dental insurances may influence your decision making indirectly, by late or less payments for your dental work. Know this fact that the less they pay to you and your doctors the more they make money. That is why they want you to go to specific doctors.
LEAST EXPENSIVE ALTERNATIVE TREATMENT
Your dental plan may only allow benefits for the least expensive treatment for a condition. For example, your dentist may recommend a crown, but your insurance may only offer reimbursement for a large fillings. As with other choices in life, such as purchasing medical or automobile insurance, or buying a home, the least expensive alternative is not always the best option.
Just like your medical insurance, your dental plan may not cover conditions that existed before you enrolled in the plan. Even though your plan may not cover certain conditions, treatment may still be necessary.
Your dental plan may not cover certain procedures, or preventive treatments such as sealants for adults that can save you money later. This does not mean these treatments are unnecessary. Your dentist can help you decide what type of treatment is best for you.