If you have ever been confused about dental insurance, you’re not alone.  Dental benefit plans are designed in a myriad of ways and benefits for the same procedure can vary greatly from plan to plan.  Generally, a dental benefit plan is a contract between a patient and their employer (or plan sponsor) and the insurance company. 

These benefit plans are designed to share in dental care costs and may not cover the whole cost of treatment.  Concerns arise when benefits offered by a plan do not cover what the patient (or the dentist) expects the contract to pay.  Your dentist typically can help explain the dental plan issues; however, even your dentist may not be able to answer specific questions or predict exactly what you level of coverage for a procedure will be.  This is because plans offered by the same employer or written by the same insurance company can vary according to the contracts involved.  Here is some of the terminology you may encounter.

UCR (usual, customary and reasonable)  

Under a UCR plan, benefits are paid on an established percentage of the plan sponsor’s “customary” or “reasonable” fee limit.  Although these limits are called customary, they may or may not reflect the normal fees of dentists in the area.  You may also find it noted on your bill that the fee charged by your dentist is higher than the usual, customary and reasonable fees.  This does not mean your dentist is overcharging you, but rather that the fee charged is above what the benefit plan was contracted to pay.  One plan will say a fee is within UCR while another plan will say the exact same fee it is too high.  The fee limitations are determined by the levels contracted between the employer and the insurance company.  There are wide fluctuations in reimbursement fees because there is no regulation as to how insurance companies determine the reimbursement levels.  In addition, insurance companies are not required to disclose how they determine these levels.  The language used in this process can be inconsistent among carriers and difficult to understand.  No wonder it is often confusing!

Annual Maximums

Your plan purchaser makes the final decision on “maximum levels” of reimbursement through a contract with the insurance company.  Dental insurance first became available in the early 1960’s.  At that time the majority of policies had a maximum annual benefit of $1000 that would be provided for the patient.  This was an excellent benefit for an employee because a great deal could be done in restoring a patient’s mouth to good health.  Unfortunately, 40+ years later, the maximum annual benefit levels have remained the same – most dental policies still have a $1000 annual limit.  Some have increased benefits to $1500, but even this improvement hasn’t kept pace with inflation.  Interesting isn’t it!

Dental insurance is an excellent benefit that has given many people the opportunity for good oral health.  Regrettably, there are a lot of misunderstandings about insurance policies that could be avoided.  Most dental offices will make every effort to assure the patient receives maximum benefits for any treatment needed, but if restorative care is extensive, it won’t be a “cure all”.  Please don’t hesitate to ask questions about your policy.  Both your employer and dentist want you to be fully informed.   

Next week I will discuss other things you may come in contact with while utilizing your dental benefits plan.