UNDERSTANDING DENTAL INSURANCE

Sorting through the complexities of insurance plans can be difficult. However, ultimately, patients are responsible for knowing their coverage. Plan sponsors (usually the employer) are required to provide booklets detailing what is and what is not covered. The intent of all dental insurance is the same: to help pay a portion of the cost of dental care. Virtually all plans limit the yearly dollar amount that will be paid.

Basically, three types of dental benefit plans exist: traditional, direct reimbursement and managed care.

Traditional or "fee-for-service" plans allow patients to seek care from the general dentist or specialist of their choice. Traditional plans provide benefits based upon either a fee schedule or a percentage of what the insurer determines to be usual, customary and reasonable (UCR) fees. Typically, most periodontal services are reimbursed at 80% or the URC fee. In addition, patients may be responsible for the difference between the UCR fee and the dental office's regular fee.

Direct reimbursement plans, the patient pays the dental bill and submits the receipt to the employer for reimbursement. There are no restrictions other than the limitation on the total dollar amount that will be paid.

Managed care plans restrict your choice of dentists. They will only pay maximum benefits if a dentist provides the services in their plan. Like traditional plans, they limit the type of frequency of care and require the patient to pay the difference between the covered amount and the dentist's fee.

With all types of plans, it is important to evaluate other plan components, such as deductibles (the amount you pay personally before the dental insurance plan kicks in); co-payments (your share of the financial responsibility for a specific dental service); limitations (such as waiting periods before coverage begins); exclusions (treatments not covered such as implants or preexisting conditions); and annual or lifetime maximum benefit (dollar limit of the insurer's financial responsibility).

If a plan doesn't cover a procedure that is recommended by your dentist, this does not mean the treatment isn't needed. It just means the plan doesn't cover it. Periodontal disease is a chronic disease that must be monitored closely. Talk with your dentist and Periodontist about the treatment you need and ask about financing options. If you value oral health and keeping your teeth, the fact that your plan does not cover your treatment should not stop you form going ahead with that treatment.

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