The following is a reprint from the CDA BROCHURE of the same name. (Used by permission.) |
While the roles you and your dentist play in maintaining your oral health are easy to understand, the role of dental benefits is sometimes unclear. Insurance industry jargon used to describe your benefits often blurs the actual terms of coverage. We encourage you to be informed on how your dental benefit plans work so that you can make the most of your coverage.
This brochure contains important information to clarify sometimes confusing aspects of dental coverage. First, some definitions...
WHAT DOES IT ALL MEAN?
UCR: A widely used method, which may vary from company to company, for determining benefit reimbursement levels. The initials simply mean:
Usual. The fee that an individual dentist most frequently charges for a given dental service.
Customary. A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area.
Reasonable. A fee which is justifiable considering special circumstances of the particular care rendered.
Table of Allowances: Assigns a specific dollar to each dental procedure.
Pre-determination: After the treatment plan is decided upon by the patient and the dentist, the insurance company reports back on what portion of the treatment plan will be covered.
Freedom of Choice: Allows the patient to choose any dentist. Coverage with this feature allows you to receive full benefits for treatment provided by any dentist of your choice.
Limitations: Limits the benefits for procedures or the number of times a procedure will be covered.
Exclusions: Denies benefit coverage for certain procedures.
Least Expensive Alternate Treatment: The insurance company's contractual arrangement with the policyholder allows the insurance company to substitute a less expensive, but in the insurance company's opinion, professionally adequate service.
HOW WELL DO YOU KNOW YOUR BENEFITS?
1. What types of dental coverage are offered by your employer or union?
2. Which procedures does your dental plan limit or exclude? Do certain procedures have waiting periods?
3. How are your benefits calculated? (UCR? Table of Allowances?)
4. Does your plan allow pre-determination of benefits?
5. Does your plan impose an annual maximum benefit level?
6. What are your co-payments?
7. Does your policy cover only the least expensive alternate treatment?
TIPS ON GETTING THE MOST FROM YOUR DENTAL PLAN.
1. Read your benefits booklet. Dental health coverage is provided by your employer or union to help you handle the costs of staying healthy. Using them wisely is your responsibility.
2. Know your options. Be familiar with the exclusions and limitations of your coverage.
3. Communicate with your dentist, employer and insurance company. Keep everyone informed of your experiences.
4. Practice good oral hygiene. Follow the hygiene habits prescribed by your dentist.
5. Ask questions. Be a partner in your own dental health.
SOME COMMONLY ASKED QUESTIONS AND ANSWERS.
Q: Why does my dental insurance pay only 50% of the charges when my policy says it will pay 80%?
A: There are several possibilities.
1. If your benefits are based on UCR calculation, it might indicate that the UCR data is out of date or not specific to your local area.
2. If you belong to a PPO, your full benefits will be paid only if you seek care from one of the contracting dentists.
3. If your benefits are calculated using a Table of Allowances, the table might be out of date or set at an unrealistically low amount.
4. If your policy provides for the least expensive treatment, you will be reimbursed the stated percentage based on the cost, even if you choose alternate treatment.
Q: Why can't I go to any dentist?
A: Many employers will contract with a closed panel or preferred provider program to contain the costs of insuring employees. As a result, your dental benefits might only be available by seeking care from a dentist who has contracted with that company.
Q: Why do my premiums keep going up?
A: Dental insurance premiums are in part based on the anticipated claims experience of your group. If that group experiences an unexpected high utilization of major dental services, the premiums will go up. Insurance company administrative costs and premium taxes also contribute to the cost of dental coverage.
Q: Is my dentist overcharging when my insurance company reimburses me for only part of the dental fees?
A: Insurance companies pay claims in various ways. Many base reimbursements on UCR rates. However, even the UCR allowance may vary from company to company. While these reimbursements usually are based on what the majority of dentists in your area charge, sometimes the figures used to calculate benefits may be out of date or not specific to your location. And, if the company uses a Table of Allowances, benefits assigned to specific dental treatment may not relate to actual costs.
WHAT DOES YOUR DENTAL BENEFIT PLAN DO FOR YOU?
Dental benefit plans help you pay for certain kinds of dental care. Your dental care decisions should take into account more than just what is covered. Your dental health needs can only be determined by you through consultation with your personal dentist. Good dental care is your right, and can best be attained by understanding your specific dental needs and how your dental benefits plan relates to them.
WHAT TYPE OF PLAN DO YOU HAVE?...NEED?...WANT?
Indemnity: Indemnity benefits are expressed as a covered fee-for-service. This coverage allows patients to choose their own dentist. Limits and co-payments are set according to the level of coverage purchased by the employer or union.
Direct Reimbursement: Enables employers to offer cost-effective dental benefits while allowing employees the freedom to choose their own dentists. The patient receives prescribed dental treatment and is reimbursed directly by the employer.
Self Insurance: The employer assumes the role of an insuring agency.
Dental Care Service Plan: A non-profit organization of participating dentists who agree to charge enrolled patients fees which do not exceed a predetermined level.
Closed Panel: Offers a limited number of facilities, and a limited number of dentists from whom care MUST be obtained.
Capitation Plan: You're assigned to a specific dental office where contracting dentists receive a fixed monthly fee per patient regardless of whether treatment is performed.
Preferred Provider Organization (PPO): A group of dentists who contract with an insurance company to provide care at discounted fees. ("Preferred" refers to a dentist who has contractually agreed to provide services at discounted fees.)
CALIFORNIA DENTAL ASSOCIATION