UNDERSTANDING YOUR DENTAL BENEFITS PLAN

A Guide For Patients

The Purpose of Dental Plans:

Employers and other plan's sponsors offer dental benefits for a variety of reasons, including promotion of oral health and attraction and retention of employees.

Regardless of why the plan is offered, its intent is the same: to help individuals by paying for a portion of the cost of their dental care.

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 (usually an insurance company).  For this reason, concerns about your dental plan should first be directed toward your plan's sponsor.

Limitations in coverage are the result of the financial commitment the plan's sponsor has agreed to make and the benefits the third-party payer will offer in exchange for that commitment.

Treatment decisions must be made by you and your dentist.  While dental benefit coverage should be taken into account, it should not be the deciding factor in your choice of treatment.

How Benefits Are Determined:

You should know how your plan is designed, since this can affect significantly the plan's coverage and your out-of pocket expense.

Some employers now offer more than one dental plan to their employees.  In fact, the right to choose between two plans could be the law in your state.  To understand and make decisions about your dental benefits, it is important to remember that dental plans are often very different.  To make the best decision for you and your family, you should understand exactly how the different kinds of dental benefit plans work and how they derive their cost savings.

There are many ways to design a dental benefits plan.  Although the features of plans may differ somewhat, the most common designs can be grouped in one of the following categories:

Direct Reimbursement programs reimburse patients a percentage of the dollar amount spent on dental care, regardless of treatment category.  This method typically does not exclude coverage based on the type of treatment needed and allows the patients to go to the dentist of their choice.

“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 to 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 may or may 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.  Most often, it does not represent the dentist's full charge for those services.  The patient pays the difference.  

Preferred Provider Organization (PPO) programs are plans under which contracting dentists agrees to discount their fees as a financial incentive for patients to select their practices.  If the patient's dentist of choice does not participate in the plan, the patient will have a reduction or complete loss of benefits.

Capitation programs pay contracted dentists a fixed amount (usually on a monthly basis) per enrolled family or patient.  In return, the dentists agrees to provide specific types of treatment to the patients at no charge (for some treatments there may be a patient co-payment).  The capitation premium that is paid may differ greatly form amount the plan provides for the patient's actual dental care.

Your plan sponsor should be able to explain the individual design features of your plan.  Design features to understand include: exclusions, limitations, patient co-payments and annual or lifetime benefit maximums.  The American Dental Association has received numerous questions and complaints from patients regarding their dental benefits.  To correct some of this confusion about dental coverage, the following questions and answers are provided by American Dental Association to help you better understand your dental benefits.  If you have additional concerns or questions, they should be directed to your group benefits department.  Your personal dentist may also be able to explain dental benefit issues and options for you.

My dentist recommends a treatment that my plan will not pay for.  Does this mean the treatment really isn't necessary?

It is common for dental plans to exclude treatment that is covered under the company's medical plans.  Some plans however, go on to exclude or discourage necessary dental treatment such as sealants, pre- existing conditions, adult orthodontics, specialist referrals and other dental needs.  Some also exclude treatment by family members.  Patients need to be aware of the exclusions and limitations in their dental plan but should not let those factors determine their dental plan, and should not let those factors determine their treatment decisions.

My dentist recommends that I get a crown on a tooth, but my dental benefit will only pay for a large filling for that tooth.  Which treatment should I have?

Some plans will only provide the level of benefit allowed for the least expensive way to treat a dental need, regardless of the decision made by you and your dentist as to the best treatment.  Sometimes, special circumstances may be explained to the third-party payer to request an adjustment to this lower benefit allowance, but there is no guarantee that the third-party payer will alter its coverage.  As in the case of exclusions, patients should base treatment decisions on their dental needs, not on their dental benefit plan.

My dental plan says that it will pay 100 percent for two dental checkups and cleanings each year.  However, I just had my first checkup and cleaning, and now the insurance company says I owe for part of the dentist's charge.  How can this be?

Plans that describe benefits in terms of percentages, for example, 100 percent for preventive care 80 percent for restorative care, are generally Usual, Customary and Reasonable (UCR) plans.  As explained in the section on “How Benefits are Determined,” the administrators of UCR plans set what the plan considers to be a “customary fee” for each dental procedure.  If your dentist's fee exceeds this customary fee, your benefit will be based on a percentage of the customary fee does not mean your dentist has overcharged for the procedure.

Will my plan cover the care my family will need?

This should be a prime consideration and major motivation in choosing one plan over another.  If your employer offers more than one plan, look at the exclusions and limitations of the coverage as well as the general categories of benefits.  You should discuss this with your family dentist before making a final decision on your dental plan.

Who is covered by my dental benefit plan?  What does my dental plan cover?

This information should be provided by the plan purchaser, often your employer or union, and by the third-party payers.  In order that you and the dentist may be aware of the benefits provided by a dental benefit plan, the extent of any benefits available under the plan should be clearly defined, limitations or exclusions described, and the application of deductibles co-payments, and co-insurance factors explained to you. This should be communicated in advance of treatment.  The plan document should describe the benefit levels of the plan and list any exclusions or limitations to that coverage.  This document should also specify who is eligible for coverage under the plan and when that coverage is in effect.

Your dentist cannot answer specific questions about your dental benefit or predict what your level of coverage for a particular procedure will be.  This is because plans written by the same third-party payer or offered by the same employer may vary according to the contracts involved.  Therefore, you should ask the plan purchaser or the third-party payer to answer your specific questions about coverage.

My dentist is not on the list of dentist provided by my employer.  Can I still go to him or her for treatment?

You can always go to the dentist of your choice.  The question is whether you will have benefit coverage for the treatment you receive if it is provided by a dentist who is not on the plan's list.  This depends on contractual agreements between the plan purchaser (often your employer), the dentists on the list and the plan administrator.  Under certain contracts, such as a PPO ( Preferred  Provider Organization) program, patients are given a financial incentive to go to certain dentists, but do receive some level of dental benefit, regardless of the treating dentist.  Other plans, such as capitation programs, do not provide any benefit coverage for treatment given by “non-participating” dentists.  In all instances where this type of plan is offered, patients should have the annual option to choose a plan that affords unrestricted choice of a dentist, with comparable benefits and equal premium dollars.

My spouse and I each have a dental benefit plan.  Whose program covers whom?  Can we decide whose program covers our children?

Your program covers you.  Your spouse's program covers him or her.  You may have additional coverage from each other's programs if they cover spouses and dependents.  In no case should the benefit derived from the two coordinated programs exceed 100 percent of the dentist's charges for treatment.

The primary plan for covering your children depends on the regulations in your state.  Most plans use “birthday rule” (spouse with birthday occurring earlier in the calendar year is primary).  Others consider the father's plan primary.  The American Dental Association has recognized the “birthday rule” as the preferred method for coordinating benefits, but which rule applies to your family depends on the language in your dental plan documents.

If you have two or more potential sources of coverage, check the coordination of benefits available.

Does my dentist have to send a description of my treatment plan to the third-party payer before I have any dental work done?  

Third-party payers often request a “predetermination of benefits” on certain treatment plans. Usually this means a dental consultant will review your dentist's treatment plan and determine what benefits your plan will provide.  But this predetermination is not a guarantee of payment.  You may want to review your benefit prior to receiving treatment, but the final treatment decision should be a matter between you and your dentist, regardless of your benefit.

There may be a provision in your plan that will deny your normal dental benefit, or reduce the level of coverage if you do not submit the treatment plan purchaser and the plan administrator and is contrary to the policy of the American Dental Association.   The American Dental Association is opposed to any dental clause that would deny or reduce payment to the beneficiary, to which he/she is normally entitled, solely on the basis or lack of preauthorization.

If You Do Not Have A Dental Benefit, You May Want To Know

I do not have a dental benefit and need some major dental work.  Where can I buy individual dental Insurance?

Dental plan coverage for individuals is not commonly offered because dental needs are highly unpredictable.  For example, you would not pay premiums for your dental coverage if the premiums were more expensive than the cost of the dental treatment you need.  Since this is the case, insurance companies would stand to lose money (spend more on benefits than they receive in the premiums) on every individual dental plan they write.

There are, however, a few companies that offer a form of dental benefits for individuals.  Most of these plans are “referral plans” or “buyers' clubs.”  Under these types of plans, an individual pays a monthly fee to a third party in return for access to a list of dentists who have agreed to a reduced fee schedule.  Payment for treatment is made from the patient directly to the dentist.  The third party acts only in the capacity of matching the individual to the dentist.  The dentist receives no payment from the third-party other than in the form of referrals.  If you have any questions please contact these companies.   

I would like to ask my employer to provide a dental benefit plan through the company.  How should I go about doing this?

The American Dental Association recognizes the important role dental benefits have played in improving access to dental care for millions of Americans.  You or your employer may contact the Association for more detailed information about how employers of all sizes can provide a cost-effective, high-quality dental benefit plan for their employees