Although dental insurances and benefit plans can make it easier to pay for dental treatment, these do not cover all the procedures that you may require and that your dentist determines you may need. This is because dental benefit plans depend on the amount of money your employer puts into it.
How do they Work?
Dental benefit plans are drawn between an insurance company and your employer who determines total coverage provided by the benefit towards your dental treatment and the procedures covered by it.
If you are not satisfied with the number of procedures covered by the dental plan provided by your employer, please let your employer know about it.
Role of the Dentist and Dental Office
To make payment easy and hassle-free, most dental offices directly file claim with your dental plan. If your treatment exceeds the coverage of your plan, then the responsibility of paying the surplus lies with you.
Key Terms and Cost Control Measures in a Dental Plan:-
1. UCR Fees (Usual, Customary and Reasonable)
This refers to the highest amount your dental plan is liable to pay against your treatment. But most UCR fees are not always “usual”, “customary” or “reasonable. This is because the insurance companies do not always set the UCR rate based on the average fees of the dentists in your locality.
And they are not liable to show you how they are setting their rate. Additionally, the UCR charges are sometimes not changed from year to year. Instead they remain static disregarding inflation and rises in the cost of dental care.
Keeping this in mind, if your dental bill is over the maximum set by your plan, it does not mean that your dentist is charging you an exorbitant price. It can simply mean that the insurance company tied up with your plan has either not updated their UCR rates or are following the rates applicable in a different part of the country.
2. Annual Maximums
This refers to the maximum amount the dental plan will cover in the course of one year. Any surplus is borne by you. If you feel the annual maximum is too low to cover your dental treatment, or it is not keeping pace with the rise in the cost of treatment, please talk to your employer about increasing the annual maximum.
3. Preferred Providers
Sometimes your dental benefit plan may provide you with a list of “preferred providers” for your treatment. This simply means that these providers have a contract with your dental plan. Using the services provided by these dentists may sometimes cost you less than what it may cost you if you use the services of a dentist outside of the network. But that is not always the case. Enquire and compare the cost of treatment of both in-the-network and out-of-the-network dentists to make a more informed choice about your treatment.
4. Pre-existing Conditions
Sometimes your dental benefit plan will not cover the treatment of any condition you had before you entered the plan. That means, if you already had a missing tooth before you signed the plan, you may not be eligible for cover for its replacement. But remember that deciding against a treatment solely because it is not covered by your plan may in fact be harmful for your health.
5. Coordination of Benefits (COB)
Also called Non-duplication of benefits, this term refers to a situation where you might be covered by more than one dental plan, which means that the total benefit from all the plans should not exceed the total cost of your treatment. Sometimes even after multiple plans your treatment may not be covered by any. Individual insurance companies handle COB in a different manner, therefore, if you have more than one plan, please refer to the document offered by each company.
6. Plan Frequency Limitation
Sometimes your dental plan will limit the number of times you can undergo the same procedure in one year. This means that if your plan covers only two cleanings of teeth each year, then you will have to pay for the additional treatments if you require four cleanings in a year. Please remember that maintaining your health is more important than the frequency of treatments offered in your plan.
7. Not Dentally Necessary
This refers to treatments that are deemed “not absolutely necessary” medically or dentally. But that does not mean they are not necessary to your unique situation. If your claim has been declined, please contact the benefits manager and submit an appeal in writing to the customer care division.
When two or more procedures are bundled under one broad heading. This can reduce the cover offered by your dental plan.
Different procedures are assigned different codes in your plan. Downcoding refers to a situation when the code of a less costly, or less complex procedure is assigned to your claim than what you underwent.
10. Least Expensive Alternative Treatment (LEAT)
This refers to a clause in your plan where the cover will be provided for only the treatment option that is least expensive out of all the options available to you. But the least expensive option may not be the best one for your condition. Talk to your dentist regarding the same and arrive at an informed conclusion regarding your treatment options.
Although it might be tempting to only go for procedures that are covered by your dental plan, always remember that your health should be your top priority, and therefore, you should make decisions based on what would give you a long-term healthy status.