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Below you will find answers to some of the most common questions asked by our patients about their dental benefits. If you cannot find question you are looking for, click the search button.
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Insurance Benefits
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| Insurance Benefits
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Q: Why doesn't my insurance cover all the costs for my treatment?
A: Dental insurance isn't really insurance at all. It is actually a money 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 the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost.
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Q: My plan says that my exams and certain other procedures are covered at 100%, but they're not. Why?
A: That 100% is usually what the insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge. For example, say your dentist charges $80 for an examination. Your carrier may allow $60 as the 100% payment for that exam, leaving $20 for you to pay.
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Q: My dentist recommends a treatment that my plan will not pay for. Does this mean the treatment really isn't necessary?
A: It is common for dental plans to exclude treatment that is covered under the company's medical plan. 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 treatment decisions.
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Q: 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 the insurance company says I owe for part of the dentist's charge. How can this be?
A: Plans that describe benefits in terms of percentages, for example, 100 percent for preventive care or 80 percent for restorative care, are generally Usual, Customary and Reasonable (UCR) plans. 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 instead of your dentist's fee. |
Q: Does my dentist have to send a description of my treatment plan to the third-party payer before I have any dental work done?
A: 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 for prior authorization. This is a contractual matter between the plan purchaser (often your employer) 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.
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Q: Who is covered by my dental benefit plan? What does my dental plan cover?
A: 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, copayments, and coinsurance 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.
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Q: My dentist is not on the list of dentists provided by my employer. Can I still go to him/her for treatment?
A: 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.
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Q: What is direct reimbursement?
A: 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.
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