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WHY DOESN'T MY INSURANCE COVER THIS?

It is your employer who chooses a plan that does not reimburse at 
the level charged by most dentists in your area.

Purpose of Plan Problems with Dental Benefits
Determination of Benefits Insurance Terminology
Usually, Customary & Reasonable Know Your Benefits
Direct Reimbursement Know Your Plan

 

The Purpose of Dental Plans

Its main purpose is 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 an employer and an insurance company. For this reason, concerns about your dental plan should first be directed to your plan sponsor.

Limitations in coverage are the result of the financial commitment your employer has agreed to make and the benefits the insurance company 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.

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How Benefits Are Determined

You should know how your plan is designed, since this can affect significantly the plan's coverage and your out-of-pocket expense.

To understand and make decisions about your dental benefits, it is important to remember that 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 their cost savings.

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The most common designs can be grouped into the following categories:
bullet"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 or "reasonable" or "customary" fee limit, whichever is less. The definition of these terms are very loose in the insurance industry but their purpose is quite clear. By setting limits on the maximum amount that the insurance company will pay per each procedure they are able to further limit their exposure even when the policy holder does not utilize all of his annual maximum.

If it is noted on your insurance statement that 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. Although these limits are called "customary," they may or may not accurately reflect the fees that area dentists charge. There is a wide fluctuation and lack of government regulation on how a plan determines the "customary" fee level.  In addition, insurance companies are not required to disclose how they determine these levels

 These very carefully chosen marketing terms do not represent any kind of mean, average or other mathematical calculation or census of fees that are actually charged by dentists for their work

Every insurance company has different UCR tables and most have several different tables.  Furthermore insurance companies are not restricted in any way from changing the UCR figures daily or even minute to minute. 

Dentists are not allowed to know what the UCR or maximum allowable fees are for any procedure.  

bulletDirect 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.
bulletTable 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.
bulletPreferred Provider Organization (PPO) programs are plans under which contracting dentists agree to discount their fees as a financial incentive for patients to select their practices. 
bulletCapitation 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. The capitation premium that is paid may differ greatly from the amount the plan provides for the patient's actual dental care.

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Your plan was specifically designed (no matter how it was marketed) to never cover anything at 100%. The simple reason for this is to deter you,  policy holder, from utilizing their benefits.

Know what  NOT receiving in benefits and the plans exclusions and limitations BEFORE you sign

Patient Problems With Dental Benefits

Your plan sponsor should be able to explain the individual design features of your plan. Design features to understand include: 
bulletExclusions-It is important to know what they don't cover  i.e. certain procedures or preventative treatments such as sealants that can save you money later.  This does NOT mean these treatments are unnecessary.
bulletLimitations-Know what preexisting conditions they won't cover and how that affects your coverage.
bulletPatient copayments are only questiments. It is illegal to accept insurance payment as payment in full for services rendered. Such practices are strictly enforced by insurers and are grounds for loss of licensure. The simple reason for this is that this practice encourages patients to utilize their benefits.
bulletAnnual or lifetime benefit maximums. Even though the cost of dental care has increase over the year, the maximum levels of insurance reimbursements have remained the same sine the late 1960! These limitations can either be per person or per family. The purpose of deductibles is to dissuade casual use of  benefits for patients prone to use their benefits for relatively minor problems and in the case of annual maximums to limit the insurance company's financial exposure for clients requiring extensive treatment
bulletLeast expensive alternative treatment for a condition.  You may need a crown but the insurance company will pay for a large filling that can lead to a broken tooth.

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Your dental plan is designed to SHARE in your dental care costs.  It may not cover the total cost of your bill.  Most plans cover between 50-80% of dental services.

    Treatment may be offered that your plan will not pay for. Does this mean the treatment really isn't necessary? Some plans 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. Do not let those factors determine your treatment decisions.

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.

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Insurance Terminology

UCR: A widely used method, which may vary from company to company, for determining benefit reimbursement levels. The initials simply mean:

Usual. The fee that an individual dentist most frequently charges for a given dental service.

Customary. A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area.

Reasonable. A fee which is justifiable considering special circumstances of the particular care rendered.

Table of Allowances: Assigns a specific dollar to each dental procedure.

Pre-determination: After the treatment plan is decided upon by the patient and the dentist, the insurance company reports back on what portion of the treatment plan will be covered.

Freedom of Choice: Allows the patient to choose any dentist. Coverage with this feature allows you to receive full benefits for treatment provided by any dentist of your choice.

Limitations: Limits the benefits for procedures or the number of times a procedure will be covered.

Exclusions: Denies benefit coverage for certain procedures.

Least Expensive Alternate Treatment: The insurance company's contractual arrangement with the policyholder allows the insurance company to substitute a less expensive, but in the insurance company's opinion, professionally adequate service.

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How to know your Benefits:

1. What types of dental coverage are offered by your employer or union?

2. Which procedures does your dental plan limit or exclude? Do certain procedures have waiting periods?

3. How are your benefits calculated? (UCR? Table of Allowances?)

4. Does your plan allow pre-determination of benefits?

5. Does your plan impose an annual maximum benefit level?

6. What are your co-payments?

7. Does your policy cover only the least expensive alternate treatment?

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Know Your Plan

1. Read your benefits booklet. Dental health coverage is provided by your employer to help you handle the costs of staying healthy. Using them wisely is your responsibility.

2. Know your options. Be familiar with the exclusions and limitations of your coverage.

3. Communicate with your dentist, employer and insurance company. Keep everyone informed of your experiences.

4. Practice good oral hygiene. Follow the hygiene habits prescribed by your dentist.

5. Ask questions. Be a partner in your own dental health.

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Dental benefit plans help you pay for certain kinds of dental care.

     Good dental care is your right, and can best be attained by understanding your specific dental needs and how your dental benefits plan relates to them.

     The fee charged is never changed from patient to patient depending on what their coverage will pay. Furthermore, our fees are set to allow us to continue to provide the highest of quality of care, service and value to our patients. We feel that this is the only ethical way to do business and we will never compromise those values. Please do not embarrass us by asking us to do so.

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Source: American Dental Association

February 06, 2008

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