Most employers have their open enrollment period for their employees to select medical/dental insurance towards the end of the year. Your decision will effect the amount of care you and your family would receive for the next benefit year and the amount that it would cost you. This article will help you understand your dental insurance, maximize your benefits and avoid common mistakes.
Employers offer dental benefits to help employees pay for a portion of the cost of their dental care. Dental plans are designed to share in the cost of your dental care, not to completely pay for those costs. Almost all dental benefit plans are the result of a contract between the plan sponsor (usually an employer or a union) and the third-party payer (usually an insurance company). Your dental coverage is determined not by your dental needs – but by how much your employer contributes to the plan.
ADA's Dental Claim Form
Key terms typically used to describe the features of a dental plan may include the following:
The maximum dollar amount a dental plan will pay annually toward the cost of dental care. The plan purchaser/employer sets the “maximum levels” of reimbursement through the contract with the insurance company. You are then responsible for paying costs above the annual maximum.
The out-of-pocket amount you have to pay before your insurance begins to kick in.
Dental treatments that are not covered by a dental plan are excluded from your benefit plan. Common examples include cosmetic services, treatment for gum disease, implants & bite therapy, and other dental needs. Over half of all the dental codes are excluded from most contracts. This does not mean that these treatments are unnecessary. Patients need to be aware of the exclusions and limitations in their dental plan but should not let those factors determine their treatment decisions. Your dentist can help you decide what type of treatment is best for you.
Dental problems that existed before your benefits became effective may not be covered. This includes plans that have a “missing tooth” exclusion. Benefits will not be paid for replacing a tooth that was missing prior to the effective date of coverage. Even though your plan may not cover certain conditions, treatment may still be necessary.
The period between your enrollment in a dental program and the date when you become eligible for a given benefit.
Plan Frequency Limitations:
Certain procedures may simply not be covered as often as necessary for optimal oral health. A common example might be a plan that pays for tooth cleaning only twice a year even though a particular patient may require cleaning every three months. Other plans, for instance, will only pay for sealants once in a lifetime, when generally sealants only last between 5 and 10 years. Limitations may vary depending on the insurance purchased. Limitations in coverage are the result of the financial commitment the plan sponsor has agreed to make and the benefits the third-party payer will offer for that commitment.
Dental insurance plans often present percentages based on 3 “categories” of services:
- Diagnostic: e.g. Exams, X-rays, simple cleanings – usually covered at 80%-100% of the insurer’s fabricated fee.
- Basic: e.g. Fillings, Extractions – usually covered at 60%-80% of the carrier’s assigned fee.
- Major: e.g. Crowns, Root Canal Therapy, Bridges, Dentures, Gum Treatment – usually covered at 0%-50% of the artificial insurance fee.
This is a term that often is applied to dentists who have a contract with the dental benefit plan. Your decision to receive dental care from preferred providers or not can affect the level of reimbursement and your out-of-pocket cost
Explanation of Benefits (EOB):
An EOB is written statement to a beneficiary, from a third-party payer, after a claim has been reported, indicating the benefit/charges covered or not covered by the dental benefit plan. Any difference between the fee charged and the benefit paid may be due to limitations in the dental plan contract.
Usual, Customary and Reasonable (UCR):
Usual, customary and reasonable charges (UCR) are the maximum amounts that will be covered by the plan for eligible services. The plan pays an established percentage of the dentist’s fee or pays the plan sponsor’s “customary” or “reasonable” fee limit, whichever is less. Although these limits are called “customary”, they may or may not reflect the fees commonly charged by dentists in the area. Exceeding the plan’s customary fee, however, does not mean your dentist has overcharged for the procedure. Why? There are no regulations as to how insurance companies determine reimbursement levels, resulting in wide fluctuations. In addition, insurance companies are not required to disclose how they determine “usual, customary and reasonable” charges.
Your out-of-pocket portion which is usually the difference between what your insurance plan pays and its UCR.
Not Dentally Necessary:
The plan provides benefits for those services and materials that they consider to be dentally necessary and meet generally accepted standards of care. Based on the information your dentist submits, the service may not appear to meet plan criteria and no benefit may be allowed. This does not mean that the services were not necessary. You or your dentist can appeal the benefit decision by submitting relevant information. The claim, along with submitted information should be reviewed by the plan’s dental consultant.
To keep the premium costs down, insurance carriers will incorporate cost-control measures into the plan design. By incorporating cost-control measures during the claims adjudication process, many times benefits are reduced or not paid at all. Some of the more common cost-control measures are:
Bundling – This is the systematic combining of distinct dental procedures by insurance companies that result in a reduced benefit for patient/beneficiary. A common example of bundling is when bitewing and periapical radiographs are combined and paid as a full mouth series of X-rays. The full mouth series is then subject to the plan’s limitation of allowing benefits, usually, once every five years for these X-rays.
Downcoding – This is the practice of insurance companies in which the benefit service code has been changed to a less complex and/or lower cost procedure than what was reported by the dentist except where delineated in contract agreements. An example is when inlays/onlays are downgraded to fillings.
Least Expensive Alternative Treatment (LEAT) – If there are several ways to fix a dental problem, the carrier will pay for the least expensive option, even if a better care is recommended. For example, your dentist may recommend a resin composite filling on a posterior tooth, but the insurance may only pay for an amalgam filling. LEAT is not always the best option for you. You should consult with your dentist on the best treatment option for you.
Coordination of Benefits and Nonduplication of Benefits:
Coordination of benefits (COB) is a method of integrating benefits payable for the same patient under more than one insurance plan. Benefits from all sources should not exceed 100% of the combined total payments.
Nonduplication of benefits is a term used to describe one of the ways the secondary carrier may calculate its portions of the payment if an enrollee is covered by two benefit plans. The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid.
Even though you may have two or more dental benefit plans in place, there is no guarantee that any of the plans will pay for your services. Please consult with you benefit plan representative for further details regarding coordination of benefits and nonduplication of benefits.
With this information, you can now make an informed decision as to which plan would be the best choice for you and your family. You can check all the insurance plans we accept at our dental practice by visiting our website at: www.ProDentCare.com/insurance.php.