Dental plans like medical plans can be confusing and frustrating. Every dental plan has basic features concerning procedures and fees. Be sure to focus on co-payments, exclusions, and limitations. Below is a list of the more common restrictions to help answer questions you may have about your denatl plan. For details and answers about your specific dental plan, ask your provider.
You have 100% coverage for a procedure, but billed by the dental plan
When a plan says that it will pay 100% of a procedure, it often means it will pay 100% of usual, customary, and reasonable (UCR) costs set by the dental plan. Any charges in excess of what the plan has determined to be the customary fee results in paying a percentage of the procedure instead of the entire amount. Remember that this does not necessarily mean that you are overcharged. Dental fees are often higher in areas where costs of operating a dental practice (dental office rent, salaries, and dental supplies) are higher. Be sure to look for the UCR clause in your dental plan and discuss the cutoff amount with your plan provider. What may be "customary" to the dental plan may be minimal for your needs.
Your dentist recommends a treatment not covered by your dental plan. Is the procedure necessary?
Dental plans cannot tell you when treatment or necessary unnecessary. Only you and your dentist make that determination. Often treatments provided by a dentist fall under a medical plan and not a dental plan. When this happens, the dental plan excludes coverage. However, some dental plans also exclude preventive treatments, which could cut costs in the future. Such treatments include sealants, sportsguards, and orthodontic braces for adults. In addition, some plans exclude certain treatments for family members. Carefully read over your dental plan so that you know exactly who and what is covered. Depending on your deductible, it may be cost effective to pay for a preventive measure now and save future treatment cost.
Providing dental care for your family
As mentioned above, some dental plans do not provide coverage for certain dental treatments for family members. Read your plan carefully to find out what you and your family can expect to have covered by the policy.
Your dental plan covers a minimal treatment, but not a better, permanent one
At times, we recommend a treatment (for example, a crown over a filling) that we feel is best. Yet the dental plan will push for a cheaper option. In this instance, it is up to you as the patient to decide what is best. You should never base treatment decisions solely on dental plan coverage. Instead, your main concern should be health and dental needs when weighing out the long-term cost.
You may not be able to choose your dentist
Dental plans often provide lists of dentists who are part of their network. You can always go to any dentist of your choice, but they may not have their fees covered by your dental plan. Some plans let you pay a percentage or a larger co-payment and then cover the remaining cost when seeing a nonmember dentist, while other plans pay nothing. If you want to go to a non-participating dentist, find out beforehand what, if any, coverage is available.
Both married partners have a dental plan. Whose covers whom?
Married couples with individual dental plans receive coverage by their specific plan. Additional coverage may be available by each plan for spouses and children. However, a combination of dental plans never exceeds 100 % coverage. Children’s coverage depends on state regulations. Often the "birthday rule" dictates which spouse’ dental plan covers children based off whose birthday occurs earlier.
It is important to understand what your dental plan covers for you and your family. Discuss your plan with you provider and make sure you understand the terms of the plan.
If you have any questions about your coverage, just ask and we will be happy to clarify.