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Understanding
Your Insurance:
Why
Doesn't My Insurance Pay For This? -- per
American Dental Association Information
"Employers
offer dental benefits to help employees pay for a portion of the cost
of their dental care. Dental plans are designed to share in the cost
of your dental care, not to completely pay for those costs. 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 payer (usually
an insurance company.) The amount your plan pays is determined by the
agreement negotiated by your employer with the insurer. Your dental
coverage is determined not by your dental needs -- but by how much your
employer contributes to the plan."
Commonly
Misunderstood Features of a Dental Plan:
UCR (Usual, Customary
and Reasonable)
Usual, customary and reasonable charges (UCR) are the
maximum amounts that will be covered by the Plan for eligible services.
The plan pays an established percentage of the dentist's fee or pays
the plan sponsor's "Customary" or "reasonable" fee
limit, whichever is less. Although these limits are called "customary,"
they may or may not reflect the fees that area dentists charge. Exceeding
these plan's customary fee, however, does not mean your dentist has
overcharged for the procedure. Why? There are no regulations as to
how insurance companies determine reimbursement levels, resulting in
wide fluctuation. In addition, insurance companies are not required
to disclose how they determine "usual, customary and reasonable"
charges.
Annual
Maximums
Most dental programs have an annual dollar maximum. This is the maximum
dollar amount a dental plan will pay towards the cost of dental care
within a specific benefit period. The plan purchaser / employer makes
the final decision on "maximum levels" of reimbursement through
the contract with the insurance company. The patient is usually
responsible for paying costs above the annual maximum. Even though the
cost of dental care has significantly increased over the years, the
maximum levels of insurance reimbursements have remained the same since
the late 1960s.Your employer may want to research plans that offer higher
anual maximums.
Preferred
Providers
The plan may want you to choose dental care from a list of their preferred
providers. This is a term that often is applied to dentists who have
a contract with thedental benefit plan. Whether or not you chose
to receive dental care from this defined group can affect the level
of reimbursement.
Pre-Existing
Conditions
Just like medical insurance, a dental plan may not cover conditions
that existed before the patient enrolled in the plan. This includes
plans that have a "missing tooth" exclusion. Benefits will
not be paid for replacing a tooth that was missing prior to the effective
date of coverage. Even though your plan may not cover certain conditions,
treatment may still be necessary.
Treatment
Exclusions
A dental plan may not cover certain procedures or preventative
treatments. Some plans exclude certain dental treatments such as
sealants, implants, pre-existing conditions, adult orthodontics, specialist
referals and other dental needs. Some also exclude coverage if the
procedure was provided by a dentist who is a family member. This does
not mean that these treatments are unnecessary. Patients need to be
aware of the exclusions and limitations in their dental plans but should
not let those factors determine their treatmen decisions. Your dentist
can help you decide what type of treatment is best for you.
Plan
Frequency Limitations
Certain procedures may simply not be covered as often as necessary for
optimal oral health. A common example might be a plan that pays for
tooth cleaning only twice a year even though a particular patient may
require cleaning every three months. Other plans, for instance, will
only pay sealants once in a lifetime, when generally sealants only last
between 5 and 10 years. Limitations may vary depending on the contract
purchased. Limitations in coverage are the result of the financial commitment
the plan sponsor has agreed to make and the benefits the third-party
payer will offer for that commitment.
Not Dentally
Necessary
The plan provides benefits for those services and materials that they
consider to be dentally necessary and meet generally accepted standards
of care. Based on the information your dentist submits, the service
may not appear to meet plan criteria and no benefit may be allowed.
You or your dentist can appeal the benefit decision by submitting relevant
information. The claim, along with the submitted information should
be reviewed by the plan's dental consultant.
Cost
Control Measures
To keep the premium costs down, insurance carriers will incorporate
cost-control measures into the plan design. By incorporating cost control
measures during the claims adjudication process, many times benefits
are reduced or not paid at all. Some of themore common cost control
measures are:
- Bundling
-- This is the systematic combining of distinct dental procedures
by third-party payers that result in a reduced benefit for the patient
/ beneficiary. A common example of bundling is when bitewing and periapical
radiographs are combined and paid as a full mouth series of X-rays.
The full mouth series is then subject to the plan's limitation of
allowing benefits, usually, once every five years for these X-rays.
- Downcoding
-- This is a practice of third-party payers in which the benefit code
has been changed to a less complex and / or lower cost procedure than
was reported except where delineated in contract agreements.
Least
Expensive Alternative Treatment
The dental plan may only allow benefits for the least expensive treatment
for a condition. For example, the dentist may recommend a resin composite
filling ona posterior tooth, but the insurance may only offer reimbursement
for an amalgam filling. As is the case of exclusions, patient should
base treatment decisions on their dental needs, not on their dental
benfit coverages. In many instances, the least expensive alternative
is not always the best option.
Direct
Reimbursement
Direct Reimbursement is a self-funded dental plan that reimburses an
individual based on a percentage of dollars spent for dental care, not
on the type of treatment provided; it also allows the patient to seek
treatment from the dentist of their choice. Unlike some forms of dental
benefits, direct reimbursement allows patients to plan treatment with
their dentists alone, with no third party interference through exclusions
(except cosmetic) or plan frequency limitations ontreatment. There are
no predetermination requirements, no pre-existing conditions, no UCR,
and typically no deductibles. In addition, there are no bundling or
downcoding or least expensive alternative treatment clauses. Please
contact the ADA at 800-232-1890 or dentalbenefits@ada.org
for more information on Direct Reimbursement.
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