Before selecting or changing a dental plan, there are some important things to consider. Some plans require patients to choose a dentist from a limited list of dentists. Choosing from a list is not the same thing as freedom of choice. If your dentist is not on such a list, don't hesitate to ask why he or she has elected not to participate.
Dental plans are typically business arrangements between an insurance company and an employer. Most plans are designed to pay only a portion of your dental expenses. However, dental plans may exclude or discourage certain treatments, such as dental sealants, which can prevent tooth decay and save you money later on. Carefully read a plan and know its limitations. If a plan doesn't cover a procedure that is recommended by your dentist, this does not mean that the treatment isn't appropriate or needed.
Some plans do not cover pre-existing conditions, such as missing teeth. Others may not cover dental implants, specialist referrals and other dental needs. Even when you and your dentist agree on the appropriate treatment method for your condition, the contract provision of the dental plan may only pay a portion, or pay only for the least expensive alternative treatment (LEAT) as determined by the insurance company.
Dental plans may use the terms "usual, customary and reasonable" (UCR) to determine the portion of the dental treatment fee they will pay. UCR reimbursement levels are determined by different methods by the dental plan administrators. They may vary a great deal among plans — even when those plans operate in the same area. The fee the insurance company determines to be "customary" may be very low compared to the area's average professional fee for the same services. The plans then generally pay a certain percentage of the UCR level. The patient may then be required to pay a greater portion of the treatment costs.
Ask yourself the following questions before selecting a new plan:
- Will employees retain the freedom to choose their own dentists?
- Is the type of treatment determined by the patient and the dentist?
- Does the plan cover diagnostic, preventive and emergency services? Will it cover preventive services such as sealants and fluoride treatments, which may save patients money in the future? Will it provide for full-mouth x-rays?
- What type of routine dental care is covered? Does the plan cover crowns and bridges, braces, root canals, oral surgery and treatment of periodontal diseases?.
- What major dental care is covered? Does the plan cover dentures, implants or treatment for temporomandibular disorders?
- Will the plan allow for referrals to specialists? If so, will the dentist be limited to a list of specialists from which to choose?
- How does the plan provide for emergency treatment? What provisions are made for emergency care when you are away from home?
- If the plan requires monthly premiums, what percentage of that money goes to actual care and not to overhead or administration?
You and your dentist make the decision about treatment. While dental benefit coverage should be taken into consideration, it should not be the deciding factor in determining your choice of treatment.
