Dental health benefit plans vary widely because each involves a negotiated contract between you or your employer, the dentist providing the care, a dental insurance carrier, and sometimes an administrator responsible for processing and payment of claims. This document will review some dental health care "basics." See the related document, "Dental Health Insurance: Frequently Asked Questions."
How benefits are determined
There are many ways that dental benefits plans are designed. You should know how your plan is designed, since this can significantly affect the plan's coverage and your out-of-pocket expense. Although the individual features of plans might differ somewhat, the most common designs can be grouped into the following categories:
Direct reimbursement programs reimburse patients a pre-determined percentage of the total dollar amount spent on dental care, regardless of treatment category. This method typically does not exclude coverage based on the type of treatment needed, allows patients to go to the dentist of their choice, and provides incentive for the patient to work with the dentist toward healthy and economically sound solutions.
"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 the plan administrator's "reasonable" or "customary" fee limit, whichever is less. These limits are the result of a contract between the plan purchaser and the third-party payer. Although these limits are called "customary," they might or might not accurately reflect the fees that area dentists charge. There is wide fluctuation and lack of government regulation on how a plan determines the "customary" fee level.
Table 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, regardless of the fee charged by the dentist. The difference between the allowed charge and the dentist’s fee is billed to the patient.
Capitation 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. (For some treatments there might be a patient co-payment.) The capitation premium that is paid might differ greatly from the amount the plan provides for the patient's actual dental care.
Dental plans limitations
To control dental treatment costs, most plans limit the amount of care you can receive in a given year. This is done by placing a dollar "cap" or limit on the amount of benefits you can receive, or by restricting the number or type of services that are covered. Some plans might totally exclude certain services or treatment to lower costs. Know specifically what services your plan covers and excludes.
There are, however, certain limitations and exclusions in most dental benefits plans that are designed to keep dentistry's costs from going up without penalizing the patient. All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there might be some less obvious exclusions. Sometimes dental coverage and health insurance might overlap. Read and understand the conditions of your dental plan. Exclusions in your dental plan might be covered by your medical insurance.
It might be wise to choose a plan that imposes dollar or service limitations, rather than one that excludes categories of service. By doing so, you can receive the care that's best for you and actively participate with the dentist in the development of treatment plans that give the most and highest quality care.
To help you stretch each dental benefit dollar, most plans provide patients and purchasers with special administrative services. Find out if your plan provides the following mechanisms to help you budget, analyze, and dispute, if necessary, the costs of your dental care.
Predetermination of costs
Some plans encourage you or your dentist to submit a treatment proposal to the plan administrator before receiving treatment. After review, the plan administrator might determine the patient's eligibility, the eligibility period, services covered, the patient's required co-payment, and the maximum limitation. Some plans require pre-determination for treatment exceeding a specified dollar amount. This process is also known as pre-authorization, pre-certification, pre-treatment review or prior authorization.
Annual benefits limitations
To help contain costs, your plan might limit your benefits by number of procedures and/or dollar amount in a given year. In most cases, particularly if you've been getting regular preventive care, these limitations allow for adequate coverage. By knowing in advance what and how much your plan allows, you and your dentist can plan treatment that will minimize your out-of-pocket expenses while maximizing compensation offered by your benefits plan.
Peer review for dispute resolution
Many plans provide a peer review mechanism through which disputes between third parties, patients, and dentists can be resolved, eliminating many costly court cases. Peer review is established to ensure fairness, individual case consideration, and a thorough examination of records, treatment procedures, and results. Most disputes can be resolved satisfactorily for all parties.
Premium adjustments and re-evaluations. Patients and plan purchasers should insist on regular reviews of premium levels to ensure that UCR or Table of Allowances payment schedules are equitable. This analysis can help optimize your benefit levels, ensuring that every dollar you spend is used wisely.
Coordination of benefits. If you are covered under two dental benefits plans, notify the administrator or carrier of your primary plan about your dual coverage status. Plan benefits coordination can help protect your rights and maximize your entitled benefits. In some cases, you might be assured full coverage where plan benefits overlap, and receive a benefit from one plan where the other plan lists an exclusion.
What key features of a dental health plan should I look for when selecting among dental plan options?
In reviewing and comparing health plans, consider the following when determining whether the coverage will satisfy your dental care needs:
- Does the plan give you the freedom to choose your own dentist or are you restricted to a panel of dentists selected by the insurance company? If restricted to a panel, is your dentist on this panel?
- Who controls treatment decisions – you and your dentist or the dental plan? Some plans might require dentists to follow the "least expensive alternative treatment approach."
- Does the plan cover diagnostic, preventive, and emergency services? If so, to what extent?
- What routine treatment is covered by the dental plan? What share of the cost will be yours?
- What major dental care is covered by the plan? What percentage of these costs will you be required to pay?
- What are the plan’s limitations (a limit to the benefits for a procedure or the number of times a procedure will be covered) and exclusions (denied coverage for certain procedures)?
- Will the plan allow referrals to dental specialists? Will my dentist and I be able to choose the specialist?
- Can you see the dentist when you need to and schedule appointment times convenient for you?
- Who is eligible for coverage under the plan and when does coverage go into effect?
Your dentist cannot answer specific questions about your dental benefit or predict what your level of coverage for a particular procedure will be. Each plan and its coverage varies according to the contracts negotiated. If you have questions about coverage, contact your employer’s benefits department, your dental health plan, or the third-party payer of your health plan.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 1/11/2013...#11182