Dental Insurance Facts

Why Doesn't My Insurance Pay for This?


This is a common question among dental patients. We have taken information gathered by the American Dental Association on this topic and hope that you find it helpful in understanding more about your dental benefits.

If your employer offer dental insurance, consider yourself fortunate. This benefit works like a valuable "coupon" that can greatly reduce the costs of dental care. However, no dental benefit plan is set up to cover all of your costs.

To avoid surprises on your dental bill, it is important to understand what your insurance will cover, and what you will need to cover some other way. Dental benefits should not be confused with the dental services you need, which are determined by you and your dentist.


How dental plans work

Almost all dental plans are the result of a contract between your employer and insurance company. The amount your plan pays is agreed upon by your employer with the insurer.

Your dental coverage is not based on what you need or what your dentist recommends. It is based on how much your employer pays into the plan. Employers generally choose to cover some, but not all, of employees' dental costs. If you are not satisfied with the coverage provided by your insurance, let your employer know.


The role of your dental office

Your dentist's main goal is to help you take good care of your teeth. Many offices will file claims with your insurance company as a service to you. The portion of the bill not covered by insurance is your responsibility. Many practices offer financing plans or other ways to help you pay your part of the bill.


Insurance terms

Key terms used to describe the features of a dental plan may include the following:

UCR (Usual, Customary, and Reasonable) - Usual, customary and reasonable charges (UCR) are the maxium amounts that will be covered by the plan. Although these terms make it sound like a UCR charge is a kind of standard rate for dental care, that is not the case. The terms "usual," "customary" and "reasonable" are misleading for several reasons:

  • UCR charges often do not reflect what dentists "usually" charge in a given area.
  • Insurance companies can set whatever they want for UCR charges - they are not required to match actual fees charged by dentists.
  • A company's UCR amounts may stay the same for many years - they do not have to keep up with inflation, for example.
  • Insurance companies are not required to say how they set theit UCR rates. Each company has it's own formula.

So if your dental bill is higher that the UCR, it does not mean your dentist has charged too much for the procedure. It could mean your insurance company has not updated its UCRs, or the data used to set UCRs is taken from areas of your state that are not similar to your community.


Annual Maximums - This is the largest dollar amount a dental plan will pay during the year. Your employer makes the final decision on maximum levels of payment through the contract with the insurance company. You are expected to pay copayments, as well as any costs above the annual maxium. Annual maximums are not always updated to keep up with the costs of dental care. If the annual maxium of your plan is too low to meet your needs, as your employer to look into plans with higher annual maxiums.


Preferred Providers - The plan may want you to choose dental care from a list of its preferred providers (dentists who have a contract with the dental benefit plan). The term "preferred" has nothing to do with the patient's personal choice of a dentist; it refers to the insurance company's choices. If you choose to receive dental care from outside the preferred provider group, you may have higher out-of-pocket costs. Inform yourself about your plan's methods for paying both in-and out-of network dentists.


Pre-existing Conditions - A dental plan may not cover conditions that existed before you enrolled for 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, treatment may still be necessary to maintain your oral health.

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