|The Purpose of Dental Plans
Employers and other plan's sponsors offer dental
benefits for a variety of reasons, including promotion of oral health,
attraction, and retention of employees.
Regardless of why the plan is
offered, its intent is the same: to help individuals by paying for a portion of
the cost of their dental care.
Almost all dental benefit plans are the
result of a contract between the plan sponsor (usually an employer or a union)
and the third-party (usually an insurance company). For this reason, concerns
about your dental plan should first be directed toward your plan's sponsor.
Limitations in coverage are the result of the financial commitment the
plan's sponsor has agreed to make and the benefits the third-party payer will
offer in exchange for that commitment.
Treatment decisions must be made
by you and your dentist. While dental benefit coverage should be taken into
account, it should not be the deciding factor in your choice of treatment.
How Benefits Are Determined
should know how your plan is designed, since this can affect significantly the
plan's coverage and your out-of pocket expense.
Some employers now
offer more than one dental plan to their employees. In fact, the right to
choose between two plans could be the law in your state. To understand and make
decisions about your dental benefits, it is important to remember that dental
plans are often very different. To make the best decision for you and your
family, you should understand exactly how the different kinds of dental benefit
plans work and how they derive there cost savings.
There are many ways
to design a dental benefits plan. Although the features of plans may differ
somewhat, the most common designs can be grouped in one of the following
Direct Reimbursement programs
reimburse patients a percentage of the dollar amount spent on dental care,
regardless of treatment category. This method typically does not exclude
coverage based on the type of treatment needed and allows the patients to go to
the dentist of their choice.
Usual, Customary and Reasonable
(UCR) programs usually allow patients to go to the dentist of their choice.
These plans pay a set percentage of the dentist's fee to the plan
administrator's reasonable or customary fee limit, whichever is less. These
limits are the result of a contract between the plan purchaser and the
third-party Payer. Although these limits are called customary, they may or may
not accurately reflect the fees that area dentists charge. There is wide
fluctuation and lack of government regulation on how a plan determines the
customary fee level.
Table or Schedule of Allowance programs
determine a list of covered services with an assigned dollar amount. That
dollar amount represents just how much the plan will pay for those services
that are covered. Most often, it does not represent the dentist's full charge
for those services. The patient pays the difference.
Provider Organization (PPO) programs are plans under which contracting
dentists agrees to discount their fees as a financial incentive for patients to
select their practices. If the patient's dentist of choice does not participate
in the plan, the patient will have a reduction or complete loss of benefits.
Capitation programs pay contracted dentists a fixed amount
(usually on a monthly basis) per enrolled family or patient. In return, the
dentists agree to provide specific types of treatment to the patients at no
charge (for some treatments there may be a patient co-payment). The capitation
premium that is paid may differ greatly form amount the plan provides for the
patient's actual dental care. These plans typically only allow the patient to
be listed with one dentist at a time and have limitations of what types of
procedures the patients can receive.
Your plan sponsor should be able to explain the
individual design features of your plan. Design features to understand include:
exclusions, limitations, patient co-payments and annual or lifetime benefit
maximums. The American Dental Association has received numerous questions and
complaints from patients regarding their dental benefits. To correct some of
this confusion about dental coverage, the following questions and answers are
provided by American Dental Association to help you better understand your
dental benefits. If you have additional concerns or questions, they should be
directed to your group benefits department. Your personal dentist may also be
able to explain dental benefit issues and options for you.
dentist recommends a treatment that my plan will not pay for. Does this mean
the treatment really isn't necessary?
It is common for dental plans
to exclude treatment that is covered under the company's medical plans. Some
plans however, go on to exclude or discourage necessary dental treatment such
as sealants, pre-existing conditions, adult orthodontics, specialist referrals
and other dental needs. Some also exclude treatment by family members. Patients
need to be aware of the exclusions and limitations in their dental plan
but should not let those factors determine their dental plan, and should not
let those factors determine their treatment decisions.
recommends that I get a crown on a tooth, but my dental benefit will only pay
for a large filling for that tooth. Which treatment should I have?
Some plans will only provide the level of benefit allowed for the least
expensive way to treat a dental need, regardless of the decision made by you
and your dentist as to the best treatment. Sometimes, special circumstances may
be explained to the third-party payer to request an adjustment to this lower
benefit allowance, but there is no guarantee that the third-party payer will
alter its coverage. As in the case of exclusions, patients should base
treatment decisions on their dental needs, not on their dental benefit plan.
My dental plan says that it will pay 100 percent for two dental
checkups and cleanings each year. However, I just had my first checkup and
cleaning, and now the insurance company says I owe for part of the dentist's
charge. How can this be?
Plans that describe benefits in terms of
percentages, for example, 100 percent for preventive care 80 percent for
restorative care, are generally Usual, Customary and Reasonable (UCR) plans. As
explained in the section on How Benefits are Determined, the administrators of
UCR plans set what the plan considers to be a customary fee for each dental
procedure. If your dentist's fee exceeds this customary fee, your benefit will
be based on a percentage of the customary fee does not mean your dentist has
overcharged for the procedure. This may arise when the cleanings are not
routine or simple in nature. There are two types of cleanings: simple
prophylaxis and a full mouth debridement. The reference to two free cleanings
per year is reserved for the simple prophylaxis procedure. There is also a
frequency on most plans that require the cleaning to be six months and a day
apart in order to receive coverage.
Who is covered by my dental
benefit plan? What does my dental plan cover?
should be provided by the plan purchaser, often your employer or union, and by
the third-party payers. In order that you and the dentist may be aware of the
benefits provided by a dental benefit plan, the extent of any benefits
available under the plan should be clearly defined, limitations or exclusions
described, and the application of deductibles co-payments, and co-insurance
factors explained to you. This should be communicated in advance of treatment.
The plan document should describe the benefit levels of the plan and list any
exclusions or limitations to that coverage. This document should also specify
who is eligible for coverage under the plan and when that coverage is in
Your dentist cannot answer specific questions about your dental
benefit or predict what your level of coverage for a particular procedure will
be. This is because plans written by the same third-party payer or offered by
the same employer may vary according to the contracts involved. Therefore, you
should ask the plan purchaser or the third-party payer to answer your specific
questions about coverage.
My dentist is not on the list of dentist
provided by my employer. Can I still go to him or her for treatment?
You can always go to the dentist of your choice. The question is
whether you will have benefit coverage for the treatment you receive if a
dentist who is not listed on the plan provides it. This depends on contractual
agreements between the plan purchaser (often your employer), the dentists on
the list and the plan administrator. Under certain contracts, such as a PPO (
Preferred Provider Organization) program, patients are given a financial
incentive to go to certain dentists, but do receive some level of dental
benefit, regardless of the treating dentist. Other plans, such as capitation
programs, do not provide any benefit coverage for treatment given by
non-participating dentists. In all instances where this type of plan is
offered, patients should have the annual option to choose a plan that affords
unrestricted choice of a dentist, with comparable benefits and equal premium
My spouse and I each have a dental benefit plan. Whose
program covers whom? Can we decide whose program covers our children?
Your program covers you. Your spouse's program covers him or her. You
may have additional coverage from each other's programs if they cover spouses
and dependents. In no case should the benefit derived from the two coordinated
programs exceed 100 percent of the dentist's charges for treatment.
primary plan for covering your children depends on the regulations in your
state. Most plans use a birthday rule (spouse with birthday occurring earlier
in the calendar year is primary). Others consider the father's plan primary.
The American Dental Association has recognized the birthday rule as the
preferred method for coordinating benefits, but which rule applies to your
family depends on the language in your dental plan documents.
have two or more potential sources of coverage, check the coordination of
Does my dentist have to send a description of my
treatment plan to the third-party payer before I have any dental work done?
Third-party payers often request a predetermination of benefits on
certain treatment plans. Usually this means a dental consultant will review
your dentist's treatment plan and determine what benefits your plan will
provide. But this predetermination is not a guarantee of payment. You may want
to review your benefit prior to receiving treatment, but the final treatment
decision should be a matter between you and your dentist, regardless of your
There may be a provision in your plan that will deny your
normal dental benefit, or reduce the level of coverage if you do not submit the
treatment plan purchaser and the plan administrator and is contrary to the
policy of the American Dental Association. The American Dental Association is
opposed to any dental clause that would deny or reduce payment to the
beneficiary, to which he/she is normally entitled, solely on the basis or lack
If You Do Not Have A Dental
Benefit, You May Want To Know
I do not have a dental
benefit and need some major dental work. Where can I buy individual dental
Dental plan coverage for individuals is not commonly
offered because dental needs are highly unpredictable. For example, you would
not pay premiums for your dental coverage if the premiums were more expensive
than the cost of the dental treatment you need. Since this is the case,
insurance companies would stand to lose money (spend more on benefits than they
receive in the premiums) on every individual dental plan they write.
There are, however, a few companies that offer a form of dental
benefits for individuals. Most of these plans are referral plans or buyers'
clubs. Under these types of plans, an individual pays a monthly fee to a third
party in return for access to a list of dentists who have agreed to a reduced
fee schedule. Payment for treatment is made from the patient directly to the
dentist. The third party acts only in the capacity of matching the individual
to the dentist. The dentist receives no payment from the third-party other than
in the form of referrals. If you have any questions please contact these
I would like to ask my employer to provide a dental
benefit plan through the company. How should I go about doing this?
The American Dental Association recognizes the important role
dental benefits have played in improving access to dental care for millions of
Americans. You or your employer may contact the Association for more detailed
information about how employers of all sizes can provide a cost-effective,
high-quality dental benefit plan for their employees.