The role your dentist plays in maintaining your oral health is easy to understand; however, the role of dental benefits is sometimes unclear. Insurance industry jargon used to describe your benefits often blurs the actual terms of coverage, and what is covered under one plan, might be excluded under another plan. We encourage you to be informed on how your dental benefit plan works so that you can make the most of your coverage. Dental benefit plans help you pay for certain kinds of dental care. Your dental care decisions should take into account more than just what is covered. Your dental health needs can only be determined through consultation with your personal dentist. Good dental care is your right, and can best be attained by understanding your specific dental needs and how your dental benefits plan relates to them.
There are many different types of insurance plans, and one of the most common misconceptions about dental insurance is the expectation that the policy will pay in much the same way that a medical plan would pay. This is simply not the case. Dental insurance is subject to yearly maximums, frequency limitations, and the limitations of usual and customary fee schedules. So what does this mean? A Usual and Customary fee is a fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area. The UCR allowance may vary from company to company. While these reimbursements usually are based on what the majority of dentists in your area charge, sometimes the figures used to calculate benefits may be out of date or not specific to your location. Furthermore, if the company uses a Table of Allowances, benefits assigned to specific dental treatment may not relate to actual costs. Many insurance companies also have a Least Expensive Alternate Treatment clause. 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 which reduces the amount the dentist is reimbursed for your treatment.
Many employers will contract with a closed panel or preferred provider program to contain the costs of insuring employees. As a result, your dental benefits might only be available by seeking care from a dentist who has contracted with that company. A PPO or Preferred Provider Organization is a group of dentists who have contracted with an insurance company to provide care at discounted fees. (“Preferred” refers to a dentist who has contractually agreed to provide services at discounted fees.) Dentists who are “in-network” have agreed to a personal contract with a benefit plan. These contracts have restrictions and requirements and usually dictate adherence to a reduced fee schedule. Therefore, patients who chose an “in-network” dentist typically will pay less of their own money toward treatment than those who choose an “out-of-network” dentist, but their treatment could be dictated by what the insurance company considers adequate treatment for your particular condition.
An “out-of-network” dentist has not signed a contract with the insurer of a particular plan. However, patients may still choose that dentist and have some of their fees covered, but they may pay more out-of-pocket. These dentists are free to prescribe the treatment they feel is best for your dental condition without the confinements of a particular insurance policy. Dr. Glass is a participating dentist in some insurance plans that allow him the freedom to practice dentistry without compromising the quality of care he provides. His office staff are experts at helping you maximize your benefits, both in network and out of network.
Bottom line, it is important that you receive regular dental care from an ethical and thorough Dentist that you trust without letting your insurance company dictate the type of treatment you will receive.