Understanding Dental Benefits
The Purpose of
Employers and other plan's sponsors offer dental
benefits for a variety of reasons, including promotion of oral health,
attraction, and retention of employees.
Regardless of why the plan is
offered, its intent is the same: 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 the plan sponsor (usually an employer or a union)
and the third-party (usually an insurance company). For this reason, concerns
about your dental plan should first be directed toward your plan's sponsor.
Limitations in coverage are the result of the financial commitment the
plan's sponsor has agreed to make and the benefits the third-party payer will
offer in exchange for that commitment.
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 treatment.
How Benefits Are
You should know how your plan is designed, since this
can affect significantly the plan's coverage and your out-of pocket expense.
Some employers now offer more than one dental plan to their employees.
In fact, the right to choose between two plans could be the law in your state.
To understand and make decisions about your dental benefits, it is important to
remember that dental 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 there cost savings.
There are many ways to design a dental benefits plan. Although the
features of plans may differ somewhat, the most common designs can be grouped
in one of the following categories:
Direct Reimbursement programs reimburse patients a
percentage of the dollar amount spent on dental care, regardless of treatment
category. This method typically does not exclude coverage based on the type of
treatment needed and allows the patients to go to the dentist of their choice.
Usual, Customary and Reasonable (UCR) programs usually allow
patients to go to the dentist of their choice. These plans pay a set percentage
of the dentist's fee to the plan administrator's reasonable or customary fee
limit, whichever is less. These limits are the result of a contract between the
plan purchaser and the third-party Payer. Although these limits are called
customary, they may or may not accurately reflect the fees that area dentists
charge. There is wide fluctuation and lack of government regulation on how a
plan determines the customary fee level.
Table or Schedule of
Allowance programs determine a list of covered services with an assigned
dollar amount. That dollar amount represents just how much the plan will pay
for those services that are covered. Most often, it does not represent the
dentist's full charge for those services. The patient pays the difference.
Preferred Provider Organization (PPO) programs are plans under
which contracting dentists agrees to discount their fees as a financial
incentive for patients to select their practices. If the patient's dentist of
choice does not participate in the plan, the patient will have a reduction or
complete loss of benefits.
Capitation programs pay contracted
dentists a fixed amount (usually on a monthly basis) per enrolled family or
patient. In return, the dentists agree to provide specific types of treatment
to the patients at no charge (for some treatments there may be a patient
co-payment). The capitation premium that is paid may differ greatly form amount
the plan provides for the patient's actual dental care. These plans typically
only allow the patient to be listed with one dentist at a time and have
limitations of what types of procedures the patients can receive.
plan sponsor should be able to explain the individual design features of your
plan. Design features to understand include: exclusions, limitations, patient
co-payments and annual or lifetime benefit maximums. The American Dental
Association has received numerous questions and complaints from patients
regarding their dental benefits. To correct some of this confusion about dental
coverage, the following questions and answers are provided by American Dental
Association to help you better understand your dental benefits. If you have
additional concerns or questions, they should be directed to your group
benefits department. Your personal dentist may also be able to explain dental
benefit issues and options for you.
My dentist recommends a
treatment that my plan will not pay for. Does this mean the treatment really
It is common for dental plans to exclude treatment
that is covered under the company's medical plans. Some plans however, go on to
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. Patients need to be aware of the
exclusions and limitations in their dental plan but should not let those
factors determine their dental plan, and should not let those factors determine
their treatment decisions.
My dentist recommends that I get a crown
on a tooth, but my dental benefit will only pay for a large filling for that
tooth. Which treatment should I have?
Some plans will only provide
the level of benefit allowed for the least expensive way to treat a dental
need, regardless of the decision made by you and your dentist as to the best
treatment. Sometimes, special circumstances may be explained to the third-party
payer to request an adjustment to this lower benefit allowance, but there is no
guarantee that the third-party payer will alter its coverage. As in the case of
exclusions, patients should base treatment decisions on their dental needs, not
on their dental benefit plan.
My dental plan says that it will pay
100 percent for two dental checkups and cleanings each year. However, I just
had my first checkup and cleaning, and now the insurance company says I owe for
part of the dentist's charge. How can this be?
Plans that describe
benefits in terms of percentages, for example, 100 percent for preventive care
80 percent for restorative care, are generally Usual, Customary and Reasonable
(UCR) plans. As explained in the section on How Benefits are Determined, the
administrators of UCR plans set what the plan considers to be a customary fee
for each dental procedure. If your dentist's fee exceeds this customary fee,
your benefit will be based on a percentage of the customary fee does not mean
your dentist has overcharged for the procedure. This may arise when the
cleanings are not routine or simple in nature. There are two types of
cleanings: simple prophylaxis and a full mouth debridement. The reference to
two free cleanings per year is reserved for the simple prophylaxis procedure.
There is also a frequency on most plans that require the cleaning to be six
months and a day apart in order to receive coverage.
Who is covered
by my dental benefit plan? What does my dental plan cover?
information should be provided by the plan purchaser, often your employer or
union, and by the third-party payers. In order that you and the dentist may be
aware of the benefits provided by a dental benefit plan, the extent of any
benefits available under the plan should be clearly defined, limitations or
exclusions described, and the application of deductibles co-payments, and
co-insurance factors explained to you. This should be communicated in advance
of treatment. The plan document should describe the benefit levels of the plan
and list any exclusions or limitations to that coverage. This document should
also specify who is eligible for coverage under the plan and when that coverage
is in effect.
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.
My dentist is not on the
list of dentist provided by my employer. Can I still go to him or her for
You can always go to the dentist of your choice. The
question is whether you will have benefit coverage for the treatment you
receive if a dentist who is not listed on the plan provides it. This depends on
contractual agreements between the plan purchaser (often your employer), the
dentists on the list and the plan administrator. Under certain contracts, such
as a PPO ( Preferred Provider Organization) program, patients are given a
financial incentive to go to certain dentists, but do receive some level of
dental benefit, regardless of the treating dentist. Other plans, such as
capitation programs, do not provide any benefit coverage for treatment given by
non-participating dentists. In all instances where this type of plan is
offered, patients should have the annual option to choose a plan that affords
unrestricted choice of a dentist, with comparable benefits and equal premium
My spouse and I each have a dental benefit plan. Whose
program covers whom? Can we decide whose program covers our children?
Your program covers you. Your spouse's program covers him or her. You
may have additional coverage from each other's programs if they cover spouses
and dependents. In no case should the benefit derived from the two coordinated
programs exceed 100 percent of the dentist's charges for treatment.
primary plan for covering your children depends on the regulations in your
state. Most plans use a birthday rule (spouse with birthday occurring earlier
in the calendar year is primary). Others consider the father's plan primary.
The American Dental Association has recognized the birthday rule as the
preferred method for coordinating benefits, but which rule applies to your
family depends on the language in your dental plan documents.
have two or more potential sources of coverage, check the coordination of
Does my dentist have to send a description of my
treatment plan to the third-party payer before I have any dental work done?
Third-party payers often request a predetermination of benefits on
certain treatment plans. Usually this means a dental consultant will review
your dentist's treatment plan and determine what benefits your plan will
provide. But this predetermination is not a guarantee of payment. You may want
to review your benefit prior to receiving treatment, but the final treatment
decision should be a matter between you and your dentist, regardless of your
There may be a provision in your plan that will deny your
normal dental benefit, or reduce the level of coverage if you do not submit the
treatment plan purchaser and the plan administrator and is contrary to the
policy of the American Dental Association. The American Dental Association is
opposed to any dental clause that would deny or reduce payment to the
beneficiary, to which he/she is normally entitled, solely on the basis or lack
You Do Not Have A Dental Benefit, You May Want To Know
not have a dental benefit and need some major dental work. Where can I buy
individual dental Insurance?
Dental plan coverage for individuals
is not commonly offered because dental needs are highly unpredictable. For
example, you would not pay premiums for your dental coverage if the premiums
were more expensive than the cost of the dental treatment you need. Since this
is the case, insurance companies would stand to lose money (spend more on
benefits than they receive in the premiums) on every individual dental plan
There are, however, a few companies that offer a form of
dental benefits for individuals. Most of these plans are referral plans or
buyers' clubs. Under these types of plans, an individual pays a monthly fee to
a third party in return for access to a list of dentists who have agreed to a
reduced fee schedule. Payment for treatment is made from the patient directly
to the dentist. The third party acts only in the capacity of matching the
individual to the dentist. The dentist receives no payment from the third-party
other than in the form of referrals. If you have any questions please contact
I would like to ask my employer to provide a dental
benefit plan through the company. How should I go about doing this?
The American Dental Association recognizes the important role
dental benefits have played in improving access to dental care for millions of
Americans. You or your employer may contact the Association for more detailed
information about how employers of all sizes can provide a cost-effective,
high-quality dental benefit plan for their employees.
|Dental Health of Longmont
|1260 South Hover Street, Unit H, Longmont, CO.
|Serving the preventative, restorative,
cosmetic and dental wellness needs for Longmont, Berthod, Mead, Niwot, Dacono,
Firestone and Frederick.
Top of Page