The best way to take full advantage of your dental insurance coverage is to read your plan information carefully and understand its features. Do not rely upon estimates given at the dental office – your financial responsibility may often exceed their best guess, which is based upon broad general guidelines provided by your plan. Contact your HR or your insurance company with specific coverage or benefit questions before each visit. This is your responsibility as an insurance product consumer, and has nothing to do with your health or the medical necessity of treatment.
Most insurance companies offer benefit plans with different features. Your employer chooses the coverage level available to you. Your dentist may or may not “participate” in the PPO network for your dental plan. If your dentist does, he or she will submit your claim. If not, you may be responsible for paying your dentist and submitting a claim to the insurance carrier.
Dental benefits are calculated within a benefit period, which is typically one year –
but not always a calendar year. Be aware of your benefits and when you are approaching deductible payments or plan maximums.
· Reimbursement Levels
· Pre-treatment Estimates
· Limitations and Exclusions
Most dental plans have an annual dollar maximum. This is the maximum dollar amount
a dental plan will pay toward the cost of dental care within a specific benefit period
(usually January through December). The patient is personally responsible for paying
costs above the annual maximum. Consult your plan booklet for specific information
about your plan.
Most dental plans have a specific dollar deductible. It works like your car insurance.
During a benefit period, you personally will have to satisfy a portion of your dental bill
before your benefit plan will contribute to your cost of dental treatment. Your plan
information will describe how your deductible works. Plans do vary on this point. For
instance, some dental plans will apply the deductible to diagnostic or preventive
treatments, and others will not.
Many insurance plans have a coinsurance provision. That means the benefit plan pays
a predetermined percentage of the cost of your treatment, and you are responsible for
paying the balance. What you pay is called the coinsurance, and it is part of your out-of-pocket
cost. It is paid even after a deductible is reached.
Many dental plans offer three classes or categories of coverage. Each class provides
specific types of treatment and typically covers those treatments at a certain
percentage. Each class also specifies limitations and exclusions (see headings on these
elsewhere in this section). Reimbursement levels vary from plan to plan, so be sure to
read your benefits information carefully.
Here is the way the three levels typically work:
Class I procedures are diagnostic and preventive and typically are covered at the
highest percentage (for example 80 percent to 100 percent of the plan’s
maximum plan allowance). This is to give patients a financial incentive to seek
early or preventive care, because such care can prevent more extensive dental
disease or even dental disease itself.
Class II includes basic procedures — such as fillings, extractions and periodontal
treatment — that are sometimes reimbursed at a slightly lower percentage (for
example, 70 percent to 100 percent).
Class III is for major services and is usually reimbursed at a lower percentage
(for example, 50 percent). Class III may have a waiting period before services
If your dental care will be extensive, you may ask your dentist to complete and submit a
request for a cost estimate, sometimes called a pre-treatment estimate, a
preauthorization or prior authorization. This will allow you to know in advance what
procedures are covered, the estimated amount the benefit plan may pay for treatment, and your
financial responsibility. A pre-treatment estimate is not a guarantee of payment. When
the services are complete, and a claim is received for payment, insurers may consider eligibility,
maximum, any deductible requirements, as well as any limitations, exclusions, etc.
Limitations and Exclusions
Dental plans are designed to help with part of your dental expenses and may not always
cover every dental need. The typical plan includes limitations and exclusions, meaning
the plan does not cover every aspect of dental care. This can relate to the type or
number of procedures, the number of visits or age limits. These limitations and
exclusions are carefully detailed in the plan booklet and warrant your attention. This
booklet can help you develop realistic expectations of how your dental plan can work for
Allowances for some procedures covered under your benefits may be subject to
limitation or denial based upon clinical criteria applied by the insurance company’s
licensed dentist or consultant staff. Insurance companies generally maintain written
guidelines for the use of clinical criteria in making benefit determinations. You may
obtain a copy of such guidelines from the insurance company by sending a request in
writing for the specific benefit category or dental procedure range.
The materials provided to you by the insurance company are guidelines used to
authorize, modify or deny coverage for persons with similar illnesses or conditions.
Specific care and treatment may vary depending on individual need and the benefits