This article was first published in 2012, a few things have since changed in the world of dental insurance, this updated version of the article is intended to address this.
The goal of your dental insurance benefit plans is to help offset the costs associated with dental care.  Typically, most plans cover between 50 and 80 percent of the cost of specific dental services.  Like medical insurance plans, dental insurance plans can be categorized as either Indemnity or managed-care plans (PPO, DHMO).

In a managed-care plans setting (PPO, DHMO), the patient is usually asked to choose his/her dental care provider from a list of the plan’s preferred providers.  This is a term used to describe dentists who contract with the dental benefit plan. Choosing your dentist from this group may or may not affect your levels of reimbursement. In my experience, unless they work in the health industry, most people don’t know or understand the reimbursement level on their dental bill.  Here are some features that are commonly misunderstood:

Yearly Maximum

The entity who purchased your dental benefits plan, usually, an employer makes the final decision on “maximum levels” of reimbursement through the contract with the insurance company; it is often based on the amount he wishes to pay for the dental benefit. Although the cost of dental care has increased significantly over the years, maximum levels of reimbursements have remained at their 1970’s level when dental insurance was first introduced. Only a few plans offer higher maximums that are try to keep up with rising dental care costs.

Deductible

Most patients with dental insurance are unaware that they may have to pay a deductible. A deductible is the fee you agree to pay in the event you get dental work, it ranges between $50 and $250 and is due annually. Once you met the value of your deductible, the dental insurance starts paying your benefits. For example, if you have a $50 deductible and your first dental visit for the year costs $150, you will owe $50 of the bill; your insurance company will owe the remaining $100. Then, the next bills will be covered base of your coverage dental benefits percentage.

It is good to always be aware of what deductible is being offered on a dental insurance policy before you buy it. Then, make sure you are willing to pay that amount.

 Customary and Reasonable

UCR (Usual, Customary and Reasonable) is a term made up by the insurance company which makes it one of the most misunderstood terms used to describe dental benefit plans. UCR plans pay an agreed upon percentage of the dentist’s fee; what the insurance company deems a “customary” or “reasonable” fee limit, whichever is less.  Although these limits are called “customary,” they generally do not reflect the actual cost of providing the dental care sought by the patient. In an explanation of benefits (EOB), a patient may note that your dentist fees are higher than the UCR reimbursement levels that his/her plan offers. This does not mean that he/she are being overcharged.

There is currently no available regulation as to how insurance companies determine reimbursement levels and they are not required to disclose how they determine these levels. This usually results in wide fluctuations.

 

Frequency and Age Limits

            This is a common cause of problems with patients and insurance coverage.  Most dental insurance policies will often have the following frequency limit wording:

  1. One time in six months, i.e. the service is paid once every 6 months, but not one day sooner
  2. Two times per calendar year, i.e. the service is paid for any date of service up to twice in a calendar year
  3. Two times in a twelve month period, i.e. the service is paid twice in a twelve month period, which may include looking back into the prior insurance year

Policies also have different frequencies for specific service types. A common example is fluoride for children. Some policy allow two cleanings in a calendar year, however only one fluoride treatment per year.  For better caries prevention, our protocol is to apply fluoride twice per year. In addition, policies who allow fluoride treatments usually have age limits (when the insurance company stop paying for fluoride treatment), which can differ from one policy to another.

Other services may also have time limitations. Some limitations often seen:

  1. Full series x-rays/panoramic x-rays are often limited to once per 3 or 5 years.
  2. Fillings are usually limited to once per every two years on the same tooth.
  3. Crowns and bridges are usually limited to one time per tooth every 5, 7 or 10 years.  Even if a crown or bridge breaks.
  4. Scalings (deep cleaning) are usually limited to 1 per quadrant per every 2 years on the same quadrant.

 Pre-existing Conditions

Just like medical insurance, a dental plan may not cover conditions that existed before a patient enrolled in the plan. In addition, the plan may not cover certain conditions for which treatment may be necessary.  Some dental plan may not cover certain procedures; this does not mean these treatments are unnecessary.  Sealants, for example, protect your teeth from caries and save you money in the future.

Missing tooth clause

In the case of a missing tooth where a bridge or an implant may be necessary, some dental policy may have a ‘missing tooth clause’. This means if the tooth was extracted prior to enrolling with the current plan, they will not pay any benefits towards restoring that tooth.

Alternate Benefits Provisions

At time, a dental insurance plan may not allow benefits for some treatment options, and suggest another less desirable treatment. For example, a dentist may recommend a crown or onlay to restore a tooth but the insurance will only pay for a large filling, which can ultimately break or break the tooth. As with other choices in life, the least expensive alternative is not always the best option.

Waiting Period

It is the length of time you must wait after you purchase your dental benefits plan before you can use your full coverage. During the waiting period, the insurance company will not pay for some procedures. This waiting period may last form a few months up to a year, depending on the type of plan. Usually, the waiting period only applies to some benefits (called major benefits); the plan will pay out on certain basic benefits once a year or every other

The details of what is covered immediately versus after the waiting period are usually outlined in your benefit contract. After the waiting period is over, then full benefits become accessible to you. Waiting periods can last up to a year on certain major procedures.

 Conclusion

As a courtesy to our patient, our staff try to assist as much as possible with dental insurance, however they are not always able answer specific questions about a patient’s benefits or predict the amount of your coverage for a specific procedure, because plans from the same issuer (Aetna, Cigna, Delta, etc) offered by the same employer may vary greatly according to the contracts involved. It is a good idea to sit down with your HR representative and review the specifics of your dental benefits or call the insurance company if you have questions about your coverage.