Frequently Asked Questions and Answers About Dental Insurance:

There are as many different dental plans as there are contracts.  Your employer has selected your plan and is ultimately responsible for how your contract is designed.  Remember, whether your plan covers a major portion of your dental bill, or only a small amount, dental benefits are good for patients because they help pay for needed treatment.  It is important to know that each contract will specify what types of procedures are considered for benefits. Even if a procedure is medically or dentally necessary, it may be excluded from your contract.  This does not mean that you do not need the procedure.  It simply means that your dental plan will not consider the procedure for payment.  For example, discretionary dental services such as cosmetic dentistry and some necessary services such as dental implants or night guards are often excluded from a dental plan.

Is it a mistake to let benefits be your sole consideration when you determine what you want to do about your dental health? Or is it wise just to get the services that are covered by your benefit plan and forgo the others? This section is provided to you to answer a few common questions about dental insurance.

Dental insurance, in reality, is not an insurance (a payment to cover the cost of a loss) at all.  It is a common misnomer.  It is actually a monitary benefit typically provided by an employer to help their employees pay for routine dental treatment.  The employer usually buys a plan based on the amount of the benefit and how much premium costs per month.  Most benefit plans are only designed to cover a portion of the total cost.

That 100% is usually what dental insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge.  Generally, the amounts allowed by the insurance companies are less than what dentists actually charge.  For example, say your dentist charges $80 for a certain procedure that your carrier claims is covered at 100%.  However, your carrier only allows $60 as the 100% payment, leaving $20 for you to pay.

Many carriers refer to their allowed payments as UCR, which stands for usual, customary and reasonable.  However, usual, customary and reasonable does not really mean exactly what it should mean.  UCR is actually a listing of payments for all covered procedures negotiated by your employer and the insurance company.  This listing is related to the cost of the premiums and your geographical area in your city and state.  Cost saving for the employer plays a major role in selection of the UCR.  Your employer has likely selected an allowed payment or UCR that corresponds to the premium cost they desire.  UCR payments could be more accurately called negotiated payments.

Usually the participating dentists on the list have agreed to a contract with the insurance carrier to lower their fees in exchange for the greater volume of patients referred to them by the insurance carrier.  In addition to lowered fees, these contracts also have restrictions on treatments.

If your desired dentist is not in your benefit plan’s network, you may want to talk to your employers’ benefits coordinator, to find out whether you can sign up for a premium plan to be able to visit out of network providers.  Most large employers offer different tiers of insurance benefits.

“Preferred Provider” as often used by the PPO plans is another term for Participating Provider.  The term “Preferred” could be misleading as one may think it relates to dentist’s credentials or technical skills.  In reality a “Preferred Provider” is preferred by the insurance company since he or she has agreed to become a participating provider.

Benefit plans are a great help in paying for regular and routine dentistry for majority of patients.  Any amount covered reduces what you have to pay out of pocket.  Use of dental services is a lot higher among those patients who have an insurance benefit vs. those who do not.

Remember that what insurance carriers call usual and customary is really what your employer and the insurance company have negotiated amongst themselves as the amount that will be paid toward your treatment.  Your dentist who is treating you has no role in deciding what usual and customary is.

Maximums limit what a carrier has to cover each year.  Dental insurance is not an insurance (by dictionary definition), it is a money benefit.  Despite the fact that costs steadily increase over time, annual maximum levels for dental care have not changed since 1960s!

In short, it is to save money.  Many dental plans allow a benefit only for the least expensive method of treatment.  For example, you may need a crown on a tooth, with your insurance company only offering a benefit towards a filling.  This does not mean you have to accept the filling.  The good news is that some benefit will be paid; but more of the fee will be your responsibility.  Your dentist’s duty is to prescribe what is best for you regardless of your insurance company’s rules and regulations.

Your plan contract specifies the frequency of certain procedures it will consider.  It may also specify that if a condition such as a missing tooth, was existing prior to the start date of the insurance plan, it may not consider a payment to treat that pre-existing condition.

Dental plans require that the network dentists observe restrictions to treatment.  Many dentists do not like the limitations imposed by insurance plans and are not comfortable with a third party intervening with how they treat their patients.