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Dental insurance can be confusing to say the least. There are a plethora of contracts and plans for patients to choose from, with each one boasting a different suite of benefits. The one you ultimately settle on is the one you believe will serve you best, but even then we find patients failing to truly understand their benefits. Remember, every policy is different. What’s important is that you choose one with dental benefits that will help cover all or at least a portion of your bills. This not only helps you to get the treatment you need to maintain good oral health, but it also enables you to operate within your budget.

Some Things to Know…

  • Become well acquainted with your policy and the various procedures and treatments that are covered by your benefits. The better you know your policy, the more you can benefit from it.

  • Not all medical and dental procedures are covered by insurance; even those that are regarded as necessary. All this means is your insurance company will not pay for the particular procedure. It doesn’t mean that you don’t need it.

  • Always consider the bigger picture. Never allow your benefits to dictate what treatment options you go for. Periodontal disease treatment, for example, is typically not covered well by dental insurance and yet, left untreated, it can lead to the development of serious health problems including stroke, diabetes, cardiovascular disease and cancer.

Frequently Asked Questions About Dental Insurance

1. FAQ: Why does my plan only cover the least expensive treatment option?

Answer: Insurance is, unfortunately, a business and one of the ways these companies save money is by exclusively offering coverage for the least expensive treatment option. So, for example, while your dentist may recommend a dental implant to replace a missing tooth, you might only be covered for a dental bridge, which isn’t as good as an implant.

This doesn’t mean that you’re forced to choose a bridge or that you have to cover the cost of the implant yourself. In many cases, insurance will cover an equivalent portion of the fee, but you will be responsible for more of the bill than you would be were you to opt for the least expensive treatment option. Remember, we here at Prestige Dental Center will recommend what is best for you and your oral health. Your insurance company’s priority is to control payments.

2. FAQ: Why doesn’t my insurance offer any coverage for X-rays, gum treatment and dental cleanings?

Answer: Procedures such as X-rays, cleanings and gum treatment are typically needed quite often, so in order to control payments, insurance companies will often provide an annual cap on the amount or number of claims you can make for these procedures. If they provided unlimited coverage for these procedures, they’d have to pay out quite a bit more!

3. FAQ: My insurance plan only kicks into gear next month; can’t my dentist just go ahead with treatment today and submit the claim when my plan goes into effect?

Answer: There is a term for this: insurance fraud. These issues are rigorously regulated by state laws and if you were to be found guilty of changing the date of your claim, both you and your dentist could be prosecuted

4. FAQ: What formula do insurance companies use to come up with their allowed payments?

Answer:Usual, Customary and Reasonable (UCR) is the term thrown around by insurance companies when determining what they’re willing to pay for and what they aren’t. In spite of what this acronym stands for, UCR is more accurately referred to as “negotiated payments”. This is why it’s so important for patients to understand their policies and what they are liable to be covered for. UCR is a listing of all the payments your insurance company is willing to make for the various procedures and treatments provided by a dentist. It is a rate negotiated by your carrier and your employer (or whoever is responsible for paying for your policy) and usually varies from city to city and from state to state.

5. FAQ: Will there always be a portion of the bill I have to pay?

Answer:Unfortunately, since the payments are negotiated, there typically is a balance that will need to be covered by the patient.

6. FAQ: What’s the point of having insurance if I still have to pay out of my pocket for treatment?

Answer:Even if you don’t get 100% or the majority portion of your treatment covered, your benefits will pay something. And, of course, every dollar your insurance pays is one less dollar you need to. In the end, it works out immensely in your favor to have assistance of this nature.

7. FAQ: If my insurance company’s “Explanation of Benefits” tells me that my dental bill is more than the UCR, is my dentist over-charging me?

Answer:Remember, the UCR – the Usual, Customary and Reasonable – is really the rate your insurance carrier and employer have negotiated, i.e. the amount that can be paid towards your dental bills. Unfortunately, this rate is usually lower than the amount any dentist will charge, which means that you will have to fork out the difference. It certainly doesn’t mean that your dentist is over-charging you.

8. FAQ: Why do my benefits come with an annual maximum? What does that mean?

Answer:The annual maximum is a pre-determined number that limits the amount of money an insurance company has to pay out each year. What can be frustrating about this whole concept is that the annual maximum for dental coverage has not been increased since the 1960’s and yet, each year, the cost of insurance premiums steadily increases.

9. FAQ: Why does my particular benefit plan give me a list of dentists from which to choose?

Answer:These dentists have signed a contract with your particular benefit plan that typically means you will pay less for dental care than you would if you opted for a dentist not on your benefit’s list. Please note that just because your dentist does not appear on this list doesn’t mean there is anything wrong with him or her. They simply haven’t yet signed a contract with your carrier.

10. FAQ: Why wouldn’t a dentist opt to sign a contract with a dental benefits network plan?

Answer:Each and every plan comes with a list of various restrictions and restraints they require dentists to observe as far as treatment is concerned. Some dentists just aren’t comfortable with this – choosing instead to base treatment solely upon what is best for the patient, rather than what’s most cost effective – and so will opt not to work with that particular plan.

11. FAQ: What if I have a problem with the amount of money my insurance company is willing to pay for a particular treatment?

Answer:Your insurance coverage and benefits is a matter that is entirely between you, your employer and your insurance company. Your dentist does not have the power or the responsibility to make your plan pay for treatment. What your dentist CAN do is help you understand what you are liable to receive for a treatment. He or she can also help you get the most out of your particular plan, but beyond that they are powerless.

Please Note: If your insurance company doesn’t cover your bills, you are liable to cover the costs. Please speak to your Employee Benefits Coordinator at your place of employment if you have any problems with this or do not quite understand your policy. Complaints may also be sent to the State Insurance Commission.


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