Understanding Insurance

Dental benefit plans are designed to share the cost of dental care. While most plans potentially cover 50% or more of the cost of dental services, your plan may not cover the total cost of treatment. Dental benefit plans are not really insurance in the traditional sense but are designed to provide you with assistance in paying for your dental care. A plan may have limitations on the number of office visits, consultations, radiographs (x-rays) and various treatments it will cover. Here are some commonly misunderstood dental plan terms and features.

 

Usual, Customary and Reasonable

“Usual, customary and reasonable” (UCR) maybe one of the most misunderstood terms used in describing dental benefits plans. UCR plans may pay an established percentage of the dentist’s fee, or what 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 that dentists in your area charge. Your explanation of benefits (EOB) may note that the fee your dentist has charged you is higher than the UCR reimbursement levels that the plan offers. This does not mean that you have been overcharged. Keep in mind that there is no regulation as to how insurance companies determine reimbursement levels, and companies are not required to disclose how they determine these levels. This results in wide fluctuations.

 

Least Expensive Alternative Treatment Provisions

Your dental plan may not allow benefits for all treatment options, even when your dentist determines that a specific treatment is in your best interest. For example, your dentist may recommend a crown, but your plan may offer reimbursement only for a large filling. As with other choices in life, such as purchasing medical or automobile insurance or buying a home, the lease expensive alternative is not always the best option.

 

What Types of Dental Plans Are There?

There are a variety of dental insurance plans that are commonly available. A comprehensive benefit package provided through your employer may give you dental coverage, or you may opt to purchase private dental insurance that is not part of an employer's benefit package.

An indemnity (Fee for Service) dental plan allows you to select any dentist and pay a percentage of the dentist’s fee for services. There may be limits from the insurer as to what is covered by the plan and what they will reimburse when you file the claim.

With the Preferred Provider Organization (PPO) dental plan, you may choose a participating network dentist at a lower cost to you. You may choose a dentist that is not a participating PPO network dentist (non-network), although you may pay more for your dental visits.

An Exclusive Provider Organization (EPO) dental plan is the same as a PPO but offers a smaller network of participating dentists and still allows for non-network access.

 

Other plans include:

Dental HMO (DHMO or managed care) dental plans cover a very specific list of procedures at defined out-of-pocket costs often referred to as “copayments” and members must choose a dentist from a list of network dentists.

With a direct reimbursement dental plan, your employer reimburses you for dental bills.