Dental Insurance Plans

Dental insurance plans have many different features, and it is important to understand them.

Some of the options are:

• Company responsible for funding benefits.

• Freedom offered in selecting the dentist.

• The benefit scale and payment methodology.

Regardless of the dental benefit plan, there are usually three parties involved in the dental insurance process:

1. You

2. The dentist.

3. A third party whom your employer has contracted for coverage.


Third Parties

There are three types of third parties.

1. Dental Service Corporations. These not-for-profit organizations negotiate and administer contracts for dental care to individuals or specific groups of patients. Delta Dental Plan and Blue Cross/Blue Shield Plans are examples of this third party type.

2. Insurance Carriers. These for-profit companies underwrite the financial risk of, and process payment claims for, dental services. Carriers contract with individuals or patient groups to offer a variety of dental benefits packages, often including both fee-for-service and managed care plans.

3. Self-Funded Insurers. These companies use their own funds to underwrite the expense of providing dental care to their employees. The company pays for the dental costs of its employees, usually with limitations on services and fixed-dollar allocations.
Predetermination of Benefits

Pre-determination of Benefits. Some plans encourage you or your dentist to submit a treatment proposal to the plan administrator before receiving treatment. After review, the plan administrator may determine: the patient's eligibility; the eligibility period; services covered; the patient's required co-payment; and the maximum limitation. Some plans require predetermination for treatment exceeding a specified dollar amount. This process is also known as preauthorization, pre-certification, pretreatment review or prior authorization.

Although your dental benefits plan may not be bound to predetermined costs, this mechanism can help you and your dentist plan and budget a treatment plan appropriate to your oral health needs.

Annual Benefits Limitations

Annual Benefits Limitations. To help contain costs, your plan may limit your benefits by number of procedures and/or dollar amount in a given year. In most cases, particularly if you've been getting regular preventive care, these limitations allow for adequate coverage. By knowing in advance what and how much your plan allows, you and your dentist can plan treatment that will minimize your out-of-pocket expenses while maximizing compensation offered by your benefits plan.
 

Eight Things to Consider When Choosing a Dental Plan

1. Does the plan give you the freedom to choose your own dentist or are you restricted to a panel of dentists selected by the insurance company? If you have a family dentist with whom you are satisfied, consider the effects changing dentists will have on the quality or quantity of care you receive. Because regular visits to the dentist reduce the likelihood of developing serious dental disease, it's best to have and maintain an established relationship with a dentist you trust.

2. Who controls treatment decisions--you and your dentist or the dental plan? Many plans require dentists to follow treatment plans that rely on a Least Expensive Alternative Treatment (LEAT) approach. If there are multiple treatment options for a specific condition, the plan will pay for the less expensive treatment option. If you choose a treatment option that may better suit your individual needs and your long-term oral health, you will be responsible for paying the difference in costs. It's important to know who makes the treatment decisions under your plan. These cost control measures may have an impact on the quality of care you'll receive.

3. Does the plan cover diagnostic, preventive and emergency services? If so, to what extent? Most dental plans provide coverage for selected diagnostic services, preventive care and emergency treatment that are basic for maintaining good oral health. But the extent or frequency of the services covered by some plans may be limited. Depending upon your individual oral health needs, you may be required to pay the dentist directly for a portion of this basic care. Find out how much treatment is allowed in any given year without cost to you, and how much you will have to pay for yourself.

Every dental care plan is different. As a basis of comparison, with the very best plans, the following services will often be covered in full, with no deductible or patient co-payment. Normally, however, there will be some co-payment by the patient.

Initial Oral Examination--once per dentist

Recall Examinations--twice per year

Complete x-ray survey--once every three years

Cavity-detecting bite-wing x-rays--once per year

Prophylaxis or teeth cleaning--twice per year

Topical Fluoride treatment--twice per year

Sealants--for those under age 18

4. What routine corrective treatment is covered by the dental plan? What share of the costs will be yours? While preventive care lessens the risk of serious dental disease, additional treatment may be required to ensure optimal health. A broad range of treatment can be defined as routine. Most plans cover 70 percent to 80 percent of such treatment. Patients are responsible for the remaining costs. Examples of routine care include:

Restorative care - amalgam and composite resin fillings and stainless steel crowns on primary teeth

Endodontics - treatment of root canals and removal of tooth nerves

Oral Surgery - tooth removal (not including bony impaction) and minor surgical procedures such as tissue biopsy and drainage of minor oral infections.

Periodontics - treatment of uncomplicated periodontal disease including scaling, root planning and management of acute infections or lesions

Prosthodontics--repair and/or relining or reseating of existing dentures and bridges.

Understand what routine dental care is covered by the plan, and what percentage of the costs will come our of your pocket.

5. What major dental care is covered by the plan? What percentage of these costs will you be required to pay? Since dental benefits encourage you to get preventive care, which often eliminates the need for major dental work, most plans are not generous when it comes to paying for major dental work, most plans cover less than 50 percent of the cost of major treatment. Most plans limit the benefits--both in number of procedures and dollar amount--that are covered in a given year. Be aware of these restrictions when choosing your plan and as you and your dentist develop treatment best suited for you. Major dental care includes:

Restorative care--gold restorations and individual crowns

Oral Surgery--removal of impacted teeth and complex oral surgery procedures.

Periodontics--treatment of complicated periodontal disease requiring surgery involving bones, underlying tissues or bone grafts.

Orthodontics--treatment including retainers, braces and/or diagnostic materials.

Dental Implants--either surgical placement or restoration

Prosthodontics--fixed bridges, partial dentures and removable or fixed dentures.

6. Will the plan allow referrals to specialists? Will my dentist and I be able to choose the specialist? Some plans limit referrals to specialists. Your dentist may be required to refer you to a limited selection of specialists who have contracted with the plan's third party. You also may be required to get permission from the plan administrator before being referred to a specialist. If you choose a plan with these limitations, make sure qualified specialists are available in your area. Look for a plan with a broad selection of different types of specialists. If you have children, you may prefer a plan that allows a pediatric dentist to be your child's primary care dentist. Since specialized treatment is generally more costly than routine care, some plans discourage the use of specialists. While many general practitioners are qualified to perform some specialized services, complex procedures often require the skills of a dentist with special training. Discuss the options with your dentist before deciding who is best qualified to deliver treatment.

7. Can you see the dentist when you need to, and schedule appointment times convenient for you? Dentists participating in closed panel or capitation plans may have select hours to see plan patients. They may schedule appointments for these patients on given days, or at specified hours of the day, restricting your access. Some dentist's fees for seeing you on weekends or during emergencies are high than those the plan allows. You may be required to pay additional costs yourself. If you select these types of plans, have a clear understanding of your dentist's policies as well as the plan's dentist-to-patient ratio. It's the best way to ensure your access to care is not unduly restricted and that you are not surprised by higher fees the plan does not cover.

8. Will the plan provide benefits to patients who may also be covered by another dental plan? It is not unusual to be eligible for dual benefits. You may be covered under your company's plan as well as under that of your spouse's employer. In analyzing your options, make sure to look for a plan that allows coordination of benefits.

Getting the Most from Your Plan

To take full advantage of your dental benefits plan, visit the dentist regularly and get the preventive care that will keep your mouth healthy. Follow the treatment plan you and your dentist have developed. Do your dental homework--brush and floss regularly and maintain a regular schedule of oral examinations and teeth cleanings.

Glossary of Terms

UCR: A widely used method, which may vary from company to company, for determining benefit reimbursement levels. The initials simply mean:
Usual. The fee that an individual dentist most frequently charges for a given dental service.

Customary. A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area.

Reasonable. A fee which is justifiable considering special circumstances of the particular care rendered.

Table of Allowances: Assigns a specific dollar to each dental procedure.

Pre-determination: After the treatment plan is decided upon by the patient and the dentist, the insurance company reports back on what portion of the treatment plan will be covered.

Freedom of Choice: Allows the patient to choose any dentist. Coverage with this feature allows you to receive full benefits for treatment provided by any dentist of your choice.

Limitations: Limits the benefits for procedures or the number of times a procedure will be covered.

Exclusions: Denies benefit coverage for certain procedures.

Least Expensive Alternate Treatment: The insurance company's contractual arrangement with the policyholder allows the insurance company to substitute a less expensive, but in the insurance company's opinion, professionally adequate service

Some of the more popular ones we accept are:

Delta Dental*
Aetna
Guardian
Met Life
Cigna
Blue Cross
Blue Shield
United Concordia
Prudential
John Hancock
New England
New York Life
Travelers

Contact Sue for assistance if you have any questions about your individual dental insurance carrier or benefits.

She can be reached at 650-965-1234.

* Please note: while we are not formally members of the Delta Dental Plan, we do accept Delta insurance in our office.