Dental health benefit plans vary widely because each involves a
negotiated contract between you or your employer, the dentist
providing the care, a dental insurance carrier, and sometimes an
administrator responsible for processing and payment of claims.
This document will review some dental health care "basics." See the
related document, "Dental Health Insurance: Frequently Asked
Questions."
How benefits are determined
There are many ways
that dental benefits plans are designed. You should know how your
plan is designed, since this can significantly affect the plan's
coverage and your out-of-pocket expense. Although the individual
features of plans might differ somewhat, the most common designs
can be grouped into the following categories:
Direct reimbursement programs reimburse patients a
pre-determined percentage of the total dollar amount spent on
dental care, regardless of treatment category. This method
typically does not exclude coverage based on the type of treatment
needed, allows patients to go to the dentist of their choice, and
provides incentive for the patient to work with the dentist toward
healthy and economically sound solutions.
"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 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 might or might 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, regardless of the fee charged by the
dentist. The difference between the allowed charge and the
dentist's fee is billed to the patient.
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
might be a patient co-payment.) The capitation premium that is paid
might differ greatly from the amount the plan provides for the
patient's actual dental care.
Dental plans limitations
To control dental
treatment costs, most plans limit the amount of care you can
receive in a given year. This is done by placing a dollar "cap" or
limit on the amount of benefits you can receive, or by restricting
the number or type of services that are covered. Some plans might
totally exclude certain services or treatment to lower costs. Know
specifically what services your plan covers and excludes.