How Dental Plans Work

Almost all dental plans are a contract between your employer and a dental insurance company (eg Delta Dental, Cigna, MetLife, etc). Your employer and the insurance negotiate the type and amount of coverage that your plan will provide, which is largely based upon how much your employer wants to spend on premium to provide this benefit to it’s employees.   This means there are good plans and not so good plans, but few patients understand the nuances until they are sitting in the dentist’s office.  If you are not satisfied with your insurance coverage, it may be useful to let your employer know.

Having dental insurance can make it easier to get the dental care you need, but very few dental plans do cover all dental procedures you might need.  In fact, dental insurance is the reverse of medical insurance.  In the medical world, you pay for the small things, and they pay for the catastrophe.  Dental insurance is structured so that they pay for the small procedures, and you pay for the big things.

Further, and like all types of insurance, dental insurance companies have a number of ways of minimize their pay out.

Cost-Control Measures Used by Dental Plans

UCR (Usual, Customary, and Reasonable) Charges
The UCR fee for a particular procedure is the maximum amount that your insurance company believes the procedure is worth.   Although these terms make it sound like the UCR fee is the standard or going rate for a dental procedure, it is not.  The terms “usual,” “customary,” and “reasonable” are misleading for several reasons:

  • Insurance companies can set whatever amount they want the UCR fee, and it frequently does not match current actual fees charges by dentists a given area.
  • Specialty dentists, who often see the most complex dental patients, often have the same UCR fee as General Dentists. This does not account for the additional time or cost associated with more complex treatment.
  • The set UCR fee may stay the same for many years. They do not adjust for inflation or the changing costs of dental care.
  • Insurance companies are not required to disclose the method by which they set their UCR rates. Each company has its own formula. 

If your dental bill is higher than the UCR listed on your insurance documents, it does not mean your dentist has charged too much.  It could mean your insurance company has not updated its UCR charges, or that the data used to set the UCR is taken from different parts of the state.   A lower UCR means, the insurance company pays less. 

Annual Maximums

This is the maximum dollar amount a dental plan will pay during the course of one calendar year.   Your employer decides the maximum levels of payment in its contract with the insurance company.   You are expected to pay copayments and any costs above the annual maximum.   Once glaring issue with dental insurance today is that annual maximums are, on average, the same today as they were 20 years ago.

Pre-Existing Conditions

A dental plan may not cover conditions that existed before you enrolled in the plan. For example, benefits will not be paid for replacing a tooth that was missing before the effective date of coverage. Even though your plan may not cover certain conditions, you may still need treatment to keep your mouth healthy.

Plan Frequency Limitations

A dental plan may limit the number of times it will pay for a certain procedure during a particular interval of time.   This is problematic when a patient needs something done more frequently than their insurance plan will allow. For example, a plan might pay for teeth cleaning only twice a year even though the patient needs a cleaning four times a year.   We recommend that you make treatment decisions based on what’s best for your health, not just what is covered by your plan.

Not Dentally Necessary

Many dental plans contain a clause that only procedures that are medically or dentally necessary will be covered. However, an insurance company does not know the individual patients they cover, and only see a snap shot of that patient’s dental record.  The insurance company’s view on the necessity of a procedure may not coincide with the patient’s view or dentist’s view.  So, if the claim is denied, it does not mean that the services were unnecessary.   You and your dentist should make treatment decisions; not your dental plan.

The Role of the Dental Office

Your dentist’s primary goal is to help you establish and maintain excellent dental health.  This does not always fit into the type of insurance plan you have, and therefore can lead to frustration and confusion.

Another wrinkle in the use of dental insurance is the concept of an “in-network” provider.   A dental office can choose to be an in-network provider for any insurance company, which means that the dental office agrees to offer a significant discount to patients with that insurance, in the hope that it will bring more patients into the practice.   Some insurance plans require that you only go to an in-network office, while other plans allow you to go to any office you choose, and still receive your dental benefit.  If your dentist is “out-of-network”, the office will usually file your insurance claim on your behalf, and the part of the bill not covered by insurance is your responsibility.

As a prosthodontic office, we frequently see patients with large-scale dental problems, and for these patients, dental insurance is of little benefit.  These patients reach their yearly maximum very quickly, and often need services that are simply “not a covered benefit”.   However, the staff at Trailhead Dental is very skilled at helping you understand and maximize your dental benefits.