Understanding Your Dental Insurance Coverage
Your Oral Health Is Our Top Priority
When deciding on treatment, dental benefits should not be top consideration. You should carefully weigh the benefits, risks, and any serious ramifications of not getting the treatment recommended.
Having said that, we also understand that having dental insurance can make it easier for you and your family to get the dental care you need. However, you may have noticed that most plans do not cover all dental procedures...
That is because your dental coverage is based on how much your employer pays into the plan and what they have negotiated with the dental insurance company. If you are not satisfied with the coverage provided by your dental insurance, please let your employer know.
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What is an Annual Maximum?
This is the maximum amount your dental plan will pay during the year. Your employer decides the maximum levels of payment in its contract with the insurance company. The contract states that you are expected to pay copayments and any costs above the annual maximum. Historically, the annual maximums have not been updated to keep up with inflation.
What is a Preferred Provider?
The plan may want you to choose dental care from its own network of dentists they are contracted with. If you get dental care from a dentist who is outside the network, you may have to pay higher out-of-pocket costs.
What is a Pre-Existing Condition?
Your 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.
What is Coordination of Benefits (COB)?
These terms apply to patients covered by more than one dental plan. The benefit payments from all insurers should not add up to more than the total charges. Even though you may have two or more dental insurances, there is no guarantee that all of the plans will pay for your services. Sometimes, none of the plans will pay the services you need. More dental insurances does not mean better.
What is Plan Frequency Limitations?
Your dental plan may limit the number of times it will pay for certain treatment. For example, you may only get one crown covered every 7 years.
What is Downcoding?
Its when a dental plan pays for a less complex or lower cost procedure than what was actually reported by the dental office. For example, if you received composite (or "tooth colored") fillings for a cavity, the insurance company may only pay for amalgam (or "silver") fillings. You are expected to pay the difference.
What is the Least Expensive Alternative Treatment?
Your plan may have the LEAT clause. This takes advantage of the fact that there is more than one way to treat a condition, and LEAT means that they will only pay for the least expensive treatment.
[Patient Education Content, American Dental Association 2016]