Understanding Dental Benefit Plans
What Is a Dental Benefit Plan?
Dental benefit plans are designed to cover (pay for) some of the costs of dental treatment. Even though most people refer to the plan that pays for their dental care as “insurance,” it’s technically a different type of healthcare plan. Dental benefit plans function differently than most health insurance plans. Your dental benefit plan may only cover some procedures fully (for example, reqular check-ups and cleanings). Some procedures will be partially covered, and some procedures may not be covered at all. You should know what your dental plan covers and what it doesn’t.
A dental benefit plan can make it more affordable to get the dental care you need. However, dental benefits should not be the only thing you consider when deciding on your treatment. Ultimately, your treatment should be determined by you and your dentist based on your health needs- not by your level of dental coverage.
How Dental Benefit Plans Work
Dental benefit plans are not designed to cover all dental procedures. Plans usually cover some, but not all, of your dental costs and needs.
Many plans involve a contract between your employer and a dental plan provider, but you can also buy individual dental plans on your own or through the health insurance marketplaces.
Your Dental Coverage Is Not Determined by Your Dentist
Your dentist’s primary goal is to help you maintain good dental health, but not every procedure your dentist recommends will be covered by your benefit plan. To avoid surprises on your bill, it’s important to understand what is covered and how much your plan will pay.
Your dental coverage is not based on what you need or what your dentist recommends. It is based on how much you or your employer pays into the plan. Sometimes, you may have a dental care need that is not covered by your plan at all. Many plans do not cover cosmetic procedures.
Key Terms for Understanding Coverage
Your dental benefit plan shares treatment costs with you- meaning they may pay part of the cost and you will pay part of the cost. There are certain cost-control measures that dental beneff plans use to share treatment costs with you.
Here are some key terms that are used to describe these measures:
Deductible
A deductible is the amount of money that you must pay before your benefit plan will pay for any service. It can take more than one service or visit to meet your deductible. Most plans don’t require a deductible for diagnostic services, like exams and x-rays, or for preventive services, like sealant application or fluoride treatment.
Coinsurance
In most cases, after you meet your deductible you will be expected to pay a percentage of the allowed benefit amount of a covered dental service. This is called coinsurance. This type of cost sharing is common in preferred provider organization (PPO) plans which are the most popular type of dental
benefit plans.
For example: Your plan may pay 80% and you pay the remaining 20% of the plan’s allowed fee to your dentist. If your plan’s allowed amount was $100, your plan pays $80 and you would pay the remaining $20.
Annual Maximum
An annual maximum is the maximum dollar amount a dental plan will pay during the year. Your employer decides the maximum levels of payment in its contract with the dental benefit provider. You would pay for anything over that set dollar amount.
For example:
Your dental expenses: $3,500
Your annual maximum: $2,000
You owe: $1,500
If the annual maximum of your plan is too low tomeet your specific needs, you may want to ask your employer to consider a higher annual maximum. If your plan also covers braces and orthodontics, there is usually a separate lifetime maximum limit.
Pre-Existing Conditions
Your dental plan may not cover conditions you had before enrolling -called pre-existing conditions. even though treatment may still be needed. You are responsible for paying these costs.
For example: If you had a missing tooth before the effective date of your coverage, benefits will not pay for replacing the tooth. Even though your plan may not cover certain conditions, you might still need treatment to keep your mouth healthy.
Coordination of Benefits (COB) or Nonduplication of Benefits
These terms apply to patients covered by more than one dental plan–for example, a plan from your employer and one from your partner’s employer. The benefit payments from all plans should not add up to more than the total charges. Even though you may have two or more dental benefit plans, there is no guarantee that all of the plans will pay for your services. Sometimes, none of the plans will pay for the services you need. Each dental plan handles coordination of benefits in its own way. You should check your dental plans for specific details
Plan Frequency Limitations
A dental plan may limit the number of times it will pay for a certain treatment. But, you may need a treatment more often to maintain good oral health. Make treatment decisions based on what’s best for your health, not just what is covered by your plan.
For example: Your plan might pay for teeth cleaning twice a year, but if you need teeth cleaning four times a year, you would pay out of pocket for the extra two cleanings.
Not Dentally Necessary
Many dental plans state that only procedures that are “medically or dentally necessary” will be covered. If the claim is denied, it does not mean that the services were not necessary. Employees at the benefits provider make decisions that do not take into consideration the clinical judgment of your dentist. Treatment decisions should be made by you and your dentist.
Other Cost-Control Measures
Procedure Bundling – Two different dental procedures are combined by the dental plan into one procedure. For example, a plan may combine the payment for a core buildup with a crown. This may reduce your benefit.
Downcoding – When a dental plan changes the procedure code to a less complex or lower cost procedure than was reported by the dental office.
Least Expensive Alternative Treatment (LEAT) – If there is more than one way to treat a condition, the plan will only pay for the least expensive treatment. However, the least expensive option is not always the best option. For example, your dentist may recommend an implant for you, but the plan may only cover less costly dentures. You should talk with your dentist about the best treatment option for you. It is important that you understand the coverage provided by your plan and your payment responsibilities to your dentist.
Non-Covered Procedures – Some procedures may be excluded from coverage under the plan.
How Do I Find Out What Is Covered?
When you sign up for your dental coverage, your dental benefit plan provider should include
a benefit plan summary. The plan summary should include a list of covered services and information about the deductible, coinsurance, annual maximums, reimbursement levels, estimated cost share, limitations, and exceptions. Check with your plan provider to find out what is covered through your dental benefits.
Make Your Dental Health the Top Priority
Although you may be tempted to make decisions about your dental care based on what your dental plan will pay, remember that your health is the most Important thing. Talk with your dentist to make sure you are getting the treatment you need.
ADA American Dental Association
Americas leading advocate for oral health