What you should knowDental benefit plans are designed to sharethe cost of dental care. While most planspotentially cover 50 percent or more ofthe cost of dental services, your planmay not cover the total cost of yourtreatment. Dental benefit plans are not really insurancein the traditional sense but are designed toprovide you with assistance in paying for yourdental care. A plan may have limitations on thenumber of office visits, consultations, radiographs(X-rays) and various treatments it will cover. Hereare some commonly misunderstood dental planterms and features.


“Usual, customary and reasonable” (UCR) may beone of the most misunderstood terms used indescribing dental benefit plans. UCR plans may payan established percentage of the dentist’s fee, orwhat the plan considers a “customary” or “reasonable”fee limit, whichever is less.

Although these limits are called “customary,”they may or may not reflect the actual fees thatdentists in your area charge. Your explanation ofbenefits (EOB) may note that the fee your dentisthas charged you is higher than the UCR reimbursementlevels that the plan offers. This does not meanthat you have been overcharged. For example, thebenefits company may not have taken into accountup-to-date data in determining a reimbursementlevel. Keep in mind that there is no regulation as tohow insurance companies determine reimbursementlevels, and companies are not required to disclosehow they determine these levels. This results inwide fluctuations.


Your dental plan may not allow benefits for alltreatment options, even when your dentist determinesthat a specific treatment is in your bestinterest. For example, your dentist may recommenda crown, but your plan may offer reimbursementonly for a large filling. As with other choices in life,such as purchasing medical or automobile insuranceor buying a home, the least expensive alternative isnot always the best option.


Your dental benefits plan purchaser (for example,your employer) makes the final decision on “maximumlevels” of reimbursement through its contractwith the insurance company. The annual maximumoften is based on the amount the employer wishesto pay for the dental benefit. Even though the costof dental care has increased significantly over theyears, the maximum levels of reimbursement havenot changed much in 30 years.


In a preferred provider arrangement, you may beasked to choose your dentist from a list of the plan’spreferred providers. These are dentists who discounttheir fees in return for being listed as practitionerswho participate in the benefit plan’s networkof providers. Whether or not you choose yourdental care provider from this defined group canaffect your reimbursement.


Just as with medical insurance, a dental plan maynot cover conditions a person had before enrolling inthe plan. Even though your plan may not cover certainconditions, treatment may be necessary. Yourdental plan may not cover certain procedures or preventivetreatments regardless of their value to you.This does not mean these treatments are unnecessary.Sealants, for example, can save you moneylater. Your dentist can help you decide what type oftreatment is best.


Dental office staff cannot always answer specificquestions about your dental benefits or predict thelevel of coverage for a particular procedure, becauseplans written by the same benefits company oroffered by the same employer may vary according tothe contracts involved. Your plan sponsor (oftenyour employer) usually is in the best position toexplain the individual design features of your planand answer specific questions about coverage. _

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