Dental Insurance

Dental insurance isn’t really insurance (a payment to cover the cost of a loss) at all. It is actually a monetary benefit typically provided by an employer to help their employees pay for routine dental treatment. The employer buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost.

Because your insurance coverage is between you, your employer and the insurance carrier, your dentist does not have the power to make your plan pay. If your insurance does not pay, you are responsible for the total cost of treatment. Sometimes a plan may pay if patients send in a claim for themselves. The Employee benefits Coordinator at your place of employment may be able to help. Patients may also lodge complaints with the state Insurance Commission.

Dentists deal with thousands of plans and hundreds of types of treatments each year. Most carriers refuse to release the details of their plans. They change policies and reimbursements constantly and without notice.

That 100% is usually what the insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge. For example, say your dentist charges $80.00 for an examination, not including x‐rays. Your carrier may allow $60.00 as the 100% payment for that examination, leaving $20.00 for you to pay.

Many carriers refer to their allowed payments as UCR, which stands for usual, customary and reasonable. However, usual, customary and reasonable does not really mean exactly what it seems to mean. UCR is a listing of payments for all covered procedures negotiated by your employer and the insurance company. This listing is related to the cost of the premiums and where you are located in you city and state. Your employer has likely selected and allowed payment or UCR payment that corresponds to the premium cost they desire. UCR payments could be accurately called negotiated payments.

Typically there is always a portion that is not covered by your benefit plan.

It does not mean that your dentist is charging too much. Remember that what insurance carriers call UCR is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment. It us usually much less than what any dentist in your area might actually charge for a dental procedure.

Maximums limit what a carrier has to cover each year. Amazingly, despite the fact that costs have steadily increased, annual maximum levels for dental care have not changed since the 1960’s.

Usually a dentist on the list has agreed to a contract with the benefit plan. These contracts have restrictions and requirements. If you choose a dentist on the list, you typically pay less toward your dental care than if you choose a dentist not on the list. If your dentist is not on the list this does not mean that something is wrong with the dentist or the office.

To save money. Your dentist may recommend a crown, with your insurance only offering a benefit toward a filling. This does not mean you have to accept the filling. The good news is that some benefit will be paid: the bad news is that more of the fee will be your responsibility. Remember that your dentist’s responsibility is to prescribe what is best for you. The insurance carriers responsibility is to control payments.

Your plan contract specifies how many of certain types of procedures it will consider annually. It limits the number of x‐rays, cleanings, etc. covered because these are the types of treatments that many people have frequently.

Dental plans used to work together.  However, many times you will get little or no coverage from a second plan. Consider any extra benefit an unexpected gift.