Dental Insurance Information - Howard County Family dentistry

How Benefits Are Determined 

You should know how your plan is designed, since this can affect significantly the plan's coverage and your out-of-pocket expense. To understand and make decisions about your dental benefits, it is important to remember that plans are often very different.

Many plans say they will pay up to 80 to 100 percent of fees, but they do not clearly specify fee schedules or annual maximums. It's more realistic to expect your dental insurance to pay 35 to 65 percent of your dental services. Although the features of plans differ somewhat, the most common plans can be grouped into the following categories.

• 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 or the insurance company's pre-set "reasonable" or "customary" fee, whichever is less. These limits are the result of a contract between your employer and the insurance company. Although these limits are called "customary," they RARELY accurately reflect the fees that area dentists charge. And exceeding the plan's customary fee does not mean you've been has overcharged for the procedure. It is our experience of dealing with more than 1,000 insurance plans that some schedules only cover 40 to 50 percent of customary fees. Others may cover up to 80 percent, with certain deductibles, maximums, and exclusions. Rarely does an insurance company cover 100 percent of dental costs.
• 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.
• Preferred Provider Organization (PPO) programs are plans under which contracting dentists agree 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.

It is very important for you to call your insurance carrier to ask questions about your benefits. We will ALWAYS do our very best to make a close estimate of what your insurance company will pay, so you know in advance approximately how much additional you will be responsible for.

Five Insurance Questions Every Patient Needs To Know

Let's look at a few common questions/myths:

Why doesn't my insurance cover all the costs for my dental treatment?

Dental insurance isn't really insurance (a payment to cover the cost of a loss) at all. It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment. The employer usually buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost.

But my plan says that my exams and certain other treatments are paid for 100%!

That 100% is usually what the insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge. Typically there is always a certain amount left for the patient to pay.

I received an Explanation of Benefits statement from my insurance carrier that says my dental bill exceeded the "usual and customary". Does this mean that my dentist is charging more than he/she should?

What insurance carriers call "usual and customary" is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment. (This amount is typically based on the premium cost for the employee and how many services the plan will cover.) The "usual and customary" is usually less and frequently much less than what any dentist in your area might actually charge for a dental procedure. It does not mean that your dentist is charging too much.

Why won't my insurance pay anything toward some procedures, such as x-rays, cleanings, and gum treatments?

Your plan contract specifies how many of certain types of procedures it will consider annually. It limits the number of x-rays, cleanings, and gum treatments it will cover because these are the types of treatments that many people need to have frequently. Too many payments for these services would make the premium cost higher.

If my insurance doesn't cover it, I don't need it...right?

It is important to know that each contract will specify what types of procedures are considered for benefits. Even if a procedure is medically and dentally necessary, it may be excluded from your contract. This does not mean that you do not need the procedure. It simply means that your plan will not consider the procedure for payment. It is a mistake to let benefits be your sole consideration when you determine what you want to do about your dental conditions. Your health is important!