Many patients have questions regarding their dental benefits. While the employee benefits coordinator where you work can best answer your questions, the following may help.
Why doesn't my insurance cover all the cost for my dental Treatment: Dental insurance isn't really an insurance ( a payment to cover loss) at all. It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment. Most plans are only designed to cover a portion of the total cost. But my plan says that my exams and certain other procedures are covered at 100%. That 100% is usually what the insurance company allows as payment toward the procedure, not what your dentist actually charges. For example say you dentist may charge $80.00 for an exam (no x-rays) your carrier only allows $60.00 as the 100% payment you are responsible for the $20.00 difference. If my plan does not really cover any procedure at 100%, why does it say it will? Benefit plan booklets are often difficult to understand. If any part of your plan is not clear to you or if you think something is wrong concerning what your plan covers, you should contact the employee benefits coordinator where you work or your insurance carrier directly. How does my insurance carrier come up with it's allowed payments? Many carriers refer to their allowed payment as UCR ( usual,customary, and reasonable). However, UCR does not really mean what it seems to mean. UCR is actually a listing of payments for all covered procedures. This listing is related to the cost of premiums in your area. UCR payments could be more accurately called negotiated payments. Since the payments are negotiated,does this mean that there is always a balance for me to pay? Typically there is always a portion not covered by your insurance plan unless your dentist is an assigned provider. If I always have a balance to pay,what good is my insurance? Even a benefit plan that does not cover a large portion of the cost of needed dentistry pays something. Any amount covered reduces what you have to pay out of pocket and any amount helps. Why is there an annual maximum on my dental insurance? Maximums limit what a carrier has to cover each year. Amazingly,despite the fact that cost have steadily increased, annual maximum levels have not changed since the 1960s. Why won't my insurance pay anything toward some procedures, such as x-rays,cleanings and gum treatments? Your plan contract specifies how many of certain types of procedures it will consider annually. It limits the number of x-rays, cleanings, and gum treatments it will cover because these are the types of procedures that many people need to have done frequently. Why doesn't my dentist participate in my dental benefits network plan? Some plans require that the network dentists observe restrictions to treatment. Many dentist are not comfortable with this. Why do some benefit plans require me to select from a list of dentist? Usually the dentist on the list have agreed to a contract with the benefit plan. So if you select a dentist out side of this list you may incur more out of pocket expense than if you chose a dentist on that list. Why does my benefit plan only pay toward the least expensive alternative treatment? To save money many dental plans allow a benefit only toward the least expensive method of treatment. Remember that it is your dentist responsibility to prescribe what is best for you. The insurance carriers job is to control payments. What should I do if my insurance doesn't pay for treatment that I think should be covered? Because your insurance coverage is between you, your employer and your carrier, your dentist does not have the power to make your plan pay. If your insurance doesn't pay,you are responsible for the total cost of treatment. The employee's benefit coordinator may be able to help or you may also lodge a complaint with the state insurance commission.