| What
is dental insurance for individuals?
Dental plan coverage for individuals is
not commonly offered because dental needs
are highly predictable. 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
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 referral of patients.
What are some questions and concerns about
dental benefits?
Your plan sponsor (often your employer)
should be able to explain the individual
design features of your plan. Design
features to understand include: exclusions,
limitations, patient copayments 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 the 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 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.
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 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.
Exceeding the plan's customary fee,
however, does not mean your dentist
has overcharged
for the procedure. These plans pay
a set percentage of the dentist's
fee or
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.
Will my plan cover the care
my family will need? This should be a prime consideration and
a 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 your family's current
and future dental needs 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, 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.
My dentist is not on the list
of dentists 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 the "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 language for each plan to determine
the 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 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.
How do I understand dental benefit plans?
Employers and other plan sponsors offer
dental benefits for a variety of reasons,
including promotion of oral health and
attraction and retention of high-quality
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
to your plan sponsor.
Limitations in coverage are the result
of the financial commitment the plan
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 are benefits 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 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 individual
features of plans may differ somewhat,
the most common designs can be grouped
into 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 or 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 agree 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 agree to provide
specific types of treatment to the patients
at no charge (for some treatments there
may be a patient copayment). The capitation
premium that is paid may differ greatly
from the amount the plan provides for
the patient's actual dental care.
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.
What is direct reimbursement?
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.
Please note: The ADA does not provide specific answers
to individual questions about fees, dental problems, conditions, diagnoses,
treatments or proposed treatments, or requests for research. Information about
dental referrals, complaints and a variety of dental procedures may
be found here. You can also refer to our Frequently
Asked Questions page for answers to common questions.
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