My dentist has recommended a treatment that is not covered by
my dental health plan. Does this mean the treatment really isn't
necessary?
It is a common practice for dental plans to
exclude treatments that are covered under a medical health plan. In
addition, many plans exclude or discourage payment for sealants,
pre-existing conditions, adult orthodontics, specialist referrals,
and other dental services. Get a copy of your dental health plan
and be aware of the exclusions and limitations in dental plan
coverage. If you don't understand any aspect of the
plan's coverage, talk with your company's benefit
administrator or call the health plan directly.
If my dentist recommends one treatment option, but my dental
insurance will only pay for a different treatment option, what can
I do?
Indeed, some plans will only pay for the least
expensive way to treat a dental need, regardless of the treatment
option selected by you and your dentist. Sometimes, the dental
health insurance company will make an adjustment to the benefit
allowance, but there is no guarantee or obligation that the company
will do this. You -- in consultation with your dentist -- should
base your treatment decision on your dental needs, and not
(necessarily) on your dental health plan coverage.
My dental plan says it pays 100 percent for a certain
procedure, yet the bill for the service says I owe for part of the
dentist's charge. What has happened?
Dental health plans
usually describe their benefits in percentages based on UCR -
"Usual, Customary, and Reasonable" -fees for each dental
procedure. If your dentist's fee is higher than this customary fee,
your dental insurance company will pay either the UCR fee limit or
a set percentage of the dentist's fee -whichever is less.
Your dentist might accept the amount received from your dental
health insurance company as "payment in full" or might bill you for
the difference between the amount billed and the amount received
from the insurance company.
The limits are the result of a contract between the plan
purchaser (your company or you as an individual) and the dental
health insurance company. Although these limits are called
"customary," they might or might not accurately reflect the fees of
dentists in your area. Additionally, there is wide fluctuation and
lack of government regulation on how a plan determines its
"customary" fee level.
Another possibility is that you sought dental care from a
dentist who was not a "preferred provider" in your dental plan.
Many health plans and dentists agree to participate in preferred
provider organizations. (Contracted dentists agree to discount
their fees in exchange for the possibility of seeing more
patients.) Plans encourage patients to seek out these dentists by
minimizing out-of-pocket expenses.) If you choose a dentist
"outside of the plan," you must pay more of the cost of the service
yourself.