Know Your Dental Plan

Dental plans, like any medical coverage plan, can be confusing and frustrating. Knowing what is covered, when, and how can be the difference between being able to handle dental costs and facing large unexpected bills.

Every dental plan has basic features concerning procedures and fees. The main features that are important to understand are co-payments, exclusions, and limitations. To help answer questions you may have about your dental plan, below is a list of the more common restrictions. For details and answers about your specific dental plan make an appointment to discuss your plan with your benefit provider.

You have 100% coverage for a procedure, but are stilled billed by the dental plan.

When a plan says that it will pay 100% of a procedure it often means it will pay 100% of usual, customary, and reasonable (UCR) costs. What is considered usual, customary, and reasonable is set by the dental plan. If your dentist charges in excess of what the plan has determined to be the customary fee, then your benefit shifts to covering a percentage of the procedure and not the entire amount. Remember that this does not necessarily mean that your dentist has overcharged. Often dental fees are higher in areas where the base costs of operating a dental practice (dental office rent, salaries, and dental supplies) are higher. Be sure to look for the UCR clause in your dental plan and discuss the cutoff amount with your plan provider. What may be "customary" to the dental plan may be minimal for your needs.

Your dentist recommends a treatment not covered by your dental plan. Is the procedure necessary?

A dental plan cannot tell you what treatment is necessary or not necessary. Only you and your dentist can make that determination. Often treatments provided by a dentist are covered under a medical plan and not a dental plan. When this happens, the dental treatment is excluded from coverage by most dental plans. However, some dental plans also exclude preventive treatments, which ironically could cut costs in the future. Such treatments may include sealants, preexisting conditions, sportsguards, and orthodontic braces for adults. In addition, some plans exclude certain treatments for family members. Carefully read over your dental plan so that you know exactly who and what is covered. Depending on your deductible it may be prudent to pay for a preventive measure now and save treatment costs in the future.

Providing dental care for your family.

As mentioned above, some dental plans do not provide coverage for certain dental treatments for family members, even if they provide them for the primary dental coverage holder. Read through your plan carefully to find out what you and your family can expect to have covered by the policy.

Your dental plan covers a minimal treatment, but not a better, permanent one.

It is not uncommon for the dentist to recommend a treatment (for example, a crown over a filling) that you both feel is best, but that the dental plan will not cover if there is a cheaper option. In this instance it is up to you as the patient to decide what is best for you. You should never base treatment decisions solely on dental plan coverage, instead your main concern should be your health and dental needs.

You may not be able to choose your dentist.

Often dental plans have a list of member dentists that you can choose from, however you are limited to that list. You can always go to any dentist of your choice, but they may not have their fees covered by your dental plan. Some dental plans let you pay a percentage or larger co-payment and cover the rest when you go to a nonmember dentist, while other plans pay nothing. If you want to go to a non-participating dentist find out beforehand what, if any, coverage is provided.

Both married partners have a dental plan. Whose covers whom?

When a couple is married and each has their own dental plans, each person is covered by their dental plan. Additional coverage may be provided by each other's plan if spouses and children are covered. However, never does a combination of dental plans ever exceed 100 % coverage. Children are covered depending on state regulations. Often the "birthday rule" is applied where the spouse whose birthday occurs earlier in the year is the one whose dental plan covers the children.

It is important to understand what your dental plan covers for you and your family. Discuss your plan with you plan provider and make sure you understand the terms of the plan. Take notes for future reference and clarification. Also, discuss with your dentist possible treatment options and fees. Your dentist cannot tell you what is covered by your personal plan, but they can inform you of possible alternative treatments. By knowing what your plan covers before you go to the dentist you can make intelligent, informed decisions as to treatments and your dental health. Smile!