Dental Insurance: Points to Consider

The following is a plain-language synopsis of most dental insurance contracts. Please read it carefully, and keep it for future reference.

Dental insurance benefits do not work in the same way as medical insurance. There is almost always a co-payment due from the patient for almost every procedure.

There are “deductibles” in all plans. At one time these deductibles were never taken out of preventive treatment (“cleanings & x-rays”). Recently many carriers have begun to take deductibles out of preventive treatment.

Fluoride treatment is considered “Standard of Care” & used to be paid for every six months. In the last few years we have seen insurance companies cover this only once a year. If you do not want fluoride treatment done, it is your responsibility to tell us that at time of treatment.

Insurance companies do not typically provide seminars or instruction book on the best method to obtain the highest financial reimbursement benefits for the patient.

Irrespective of any dental insurance benefits that might exist, the patient is always legally responsible for the entire cost of dental treatment.

The extent of dental coverage is solely dependent on the dental insurance plan purchased by the employer. The higher the premium the employer pays, the greater the dental insurance benefits.

Even if there is a written predetermination of benefits returned from the insurance carrier, it is possible that after treatment is provided, there are no insurance benefits payable.

The letters UCR on insurance vouchers stand for Usual, Customary, and Reasonable fee.  The dollar amount you see as UCR has no basis in reality. It is an arbitrary amount determined solely by the plan selected and insurance premium paid by the employee. There is no relationship to the actual dental office fee. The better the plan (i.e., the more premium paid), the higher the UCR will be.

A single insurance carrier may have a dozen different UCR fees for the same procedure, same office and same dentist.

There is no universal coverage and payment schedule established.  Just because an insurance code describing a dental service exists, it does not guarantee that it will be a paid benefit under your policy. There are many dental procedures that are necessary, and many of them are preventive, but are not covered benefits.

Financial benefits cannot be saved and carried over into the next year.

Your dental benefits almost always have a yearly maximum contribution level. The amount is the most your insurance carrier is contractually obligated to pay during a defined year (calendar or otherwise). When this amount is reached, there will be no further dental benefits payable until the next benefit year.  If you have already begun some additional dental treatment prior to the maximum being reached, the insurance carrier has no payment obligation beyond that of the annual maximum.