Many people are enrolled in group dental programs offered by their employers. Often, we equate our dental benefits with our group health insurance plans. We think in terms of full coverage for treatment, with high benefit limits, co-payments for office visits and complete prescription drug coverage.
In reality, the group dental plans offered by most insurance companies are not dental insurance at all, they are really dental assistance plans. It is important to understand that dental coverage is designed to defray only part of the cost of dental care. In many cases, dental programs will not cover every dollar of dental expense when treatment is received, even if the charges are considered covered expenses under the terms of the plan.
How could this be?
Most dental plans are composed of three parts:
- Routine/Preventive Care -covers exams, cleanings, x-rays and sealants
- Basic Services -covers fillings, root canal, extractions
- Major Services (Most expensive treatments) -covers gold fillings, inlays and crowns
Many dental plans offer an orthodontia benefit. This benefit would cover part of the cost for braces for children under the age of 19. Most dental programs will not cover the cost of adult orthodontia. If orthodontia is offered, the standard is 50% coverage to a lifetime maximum benefit of $1000.
Typical dental reimbursement is as follows:
- Routine/Preventive Care -(usually with no deductible) -100% coverage
- Basic Services (usually $25 or $50 deductible per person in the family) -80% coverage after satisfaction of a deductible
- Major Services (after the deductible is satisfied) -50% coverage
NOTE: Prescriptions written by dentists are often not covered by dental plans.
The maximum benefit paid by most dental plans is $1000 per person in a calendar year. A few plans may pay $1500 per person. The richest dental plan pays as much as $2000 per person per year. This is much less than the maximum benefit paid by the average health insurance plan. It is worth noting that insurance carriers pay usual, customary and reasonable charges when considering dental claims. Charges beyond UCR are the patient's responsibility.
The best way to maximize your dental benefit is to do a pre-determination. Ask your dentist to send a plan of treatment to your dental carrier. The insurance company will tell you and your dentist exactly what they will pay in benefits before any work is done.
Many employers offer Section 125 cafeteria plans wherein employees can budget pre-tax dollars from their pay in order to find dental expenses not covered by their dental plans. It makes good economic sense to use pre-tax dollars to pay for dental expenses.
By working with your dentist, your insurance company and your employer, you can have the dental care you need and manage the expense without breaking your budget.
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