Dental Insurance Benefits
Dental benefits have become an integral part of health care planning for many families. Dental benefit plans are made available to employees or members through companies, unions, and associations, and may vary considerably from one plan to the next.
The range of benefits depends solely on what the plan purchaser wished to offer to employees or members. Some plans base the amount of benefit on a chart or schedule of fees arbitrarily developed by insurance companies. This chart or schedule determines which fees are considered “usual, customary, and reasonable” (UCR). Dental plans may use UCR to determine the portion of the dental treatment fee they will pay. UCR reimbursement levels are determined by different methods by the dental plan administrators. They may vary a great deal among plans, even when those plans operate in the same area. The fee the insurance company determines to be “customary” may be very low compared to the area’s average professional fee for the same services. The plans then generally pay a certain percentage of the UCR level.
For this reason, you may receive a lower percentage of the reimbursement level indicated in your dental plan. For example, if your plan states that it will pay 80% of the usual and customary cost of dental treatment, it means 80% of the fee determined by the insurance company, and not the actual fee charged by the dentist.
Any portion of a dental bill that is not covered by your plan is your responsibility.
Your dental plan may not cover conditions that existed before you enrolled in their plan, often called pre-existing conditions. Treatment may still be necessary for some conditions. Each dental benefit plan also has its own guidelines for which treatment is “dentally necessary.” If a procedure falls into this category, you may have to pay out-of-pocket. This does not mean the treatment is not necessary. It simply means your insurance provider defines it that way. There is an appeals process available should your dentist consider a procedure necessary that is not covered by your benefit plan. Although you may be tempted to decide on your dental care based on what insurance will pay, always remember that your health is more important than the price tag. The least expensive option is not always the best.