| 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.
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.
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.
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.
|
