Understanding Your Insurance

Why doesn't my dental insurance pay for this? (ADA excerpt)

If your employer offers dental insurance, consider yourself fortunate. This benefit works like a valuable “coupon” that can greatly reduce the costs of your 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 or plan sponsor and an insurance company. There are many ways in which dental plans are designed and how reimbursement levels are determined. The amount your plan pays is agreed upon by your employer with the insurer. Your dental plan is designed to share your dental care costs. It will most likely not cover the total cost of the services provided by our office. Most dental insurance plans cover between 50% – 80% of our fees for the services that we provide.

Your dental coverage is not based on what your needs 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 the employees’ dental costs. You need to know how your dental plan is designed – and its limitations.

Below are some key terms used to describe the features of a dental plan

  • What is UCR (Usual, Customary and Reasonable)
  • What is my Annual Maximum
  • Preferred Providers
  • Pre-existing Conditions
  • Coordination of Benefits (COB) and Nonduplication of Benefits
  • Plan Limits
  • Not Dentally Necessary
  • Least Expensive Alternative Treatment (LEAT)
  • Explanation of Benefits (EOB)

What is UCR (Usual, Customary and Reasonable)?

Usual, customary and reasonable charges (UCR) are the maximum amounts that will be covered by the plan for eligible services. The plan pays an established percentage of your dentist fees or pays the plan sponsor’s “customary” fee limit, whichever is less.

Should this charge exceed the plan’s customary fee, this does not mean your dentist has overcharged for the procedure. Why? There are no regulations as to how insurance companies determine reimbursement levels, resulting in wide fluctuations. In addition, insurance companies are not required to disclose how they determine “usual, customary and reasonable” charges.

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
  • The insurance company may not have taken into account up-to-date, non-biased, regional data in determining their reimbursement levels
  • Insurance companies are not required to say how they set their UCR rates – each company has its own formula

What is my Annual Maximum?

This is the largest dollar amount a dental plan will pay during the contract year. Your employer makes the final decision on maximum levels of payment through the contract with the insurance company. You are expected to pay the copayments and deductibles, 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.

Preferred Providers

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.

Pre-existing Conditions

A dental plan may not cover conditions that existed before you are 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) and Non-duplication 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 want to know if you have coverage from other companies 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 any of the plans will pay for your dental services. Sometimes, none of the plans will pay for the services that are needed.

Non-duplication of Benefits is extremely tricky in that both parents could be paying premiums for dental insurance coverage for their children, but only one insurance company is going to make any payments. This allows insurance companies to collect premiums, but not have to make any payments to dental providers for your children’s dental care. We always recommend that one parent discontinue dental insurance coverage if both coverages are non-duplication of benefits as there is no benefit for paying for the second coverage.

Each insurance company handles the Coordination of Benefits and Nonduplication of Benefits in its own way. Please check your plan for details.

Plan Limits

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 once for best oral health. For example, a plan might pay for teeth cleaning only twice a year even though you need cleaning four times a year. Be aware of the details in your dental plan but decide about the 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 charge may not be reimbursed.

However, that does not mean that 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 dentist about 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.

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