CLARIFYING YOUR DENTAL INSURANCE
Dental insurance can be confusing, and insurance plans are all a bit different.
Dental insurance plans are a contract between you, your insurance provider, and perhaps your employer. Our office has no control over this contract, but we do want to help make the information clear.
There are several types of dental insurance, including direct reimbursement, preferred provider organizations, capitation, and indemnity plans.
Direct Reimbursement Plans
In direct reimbursement plans, your employer reimburses you directly for all or part of your dental care expenses. Usually, all types of dental treatments are covered and you can see any dentist you choose.
Preferred Provider Organization Plans (PPO)
In a preferred provider organization plan you can choose any dentist, but the plan will pay a higher percentage of the fees if you choose from a specific network of dentists who have agreed to discount their fees in order to be part of the plan.
Health Maintenance Organization Plan (HMO)
With this type of insurance plan you must see network doctors in order to receive insurance benefits.
In a capitation plan, the plan pays participating dentists a set amount for each patient enrolled in the plan, whether you visit the dentist or not.
The most common insurance programs are indemnity plans. These plans allow you to go to any doctor, anywhere. You pay for routine care outright, and other services are paid 20 percent by you, and 80 percent by the insurance carrier.
Usual, Customary, & Reasonable (UCR) Fees
This term is often used in insurance policies to describe the amount of coverage for a particular service.
Most people assume insurance companies have gathered statistics, and that these statistics are the basis for UCR fees. In most cases, this isn’t true. These UCR fees are usually not representative of local dentist’s fees. They are often fees based on nationwide averages of dental clinic fees. There appears to be no rhyme or reason for the fees — the same insurance company may pay different UCR fees to the same dental office, depending on the plan purchased by different employers. Dental plans may also pay a different UCR for the same geographical area, and for the same group of dentists.
The Choice Is Yours
Patients often need dental treatment that is not covered, or not fully covered, by their insurance provider.
Dental plans generally set which dental services will be covered and which will not. Many dental plans cover only lower quality materials and services, and these may not be the best treatment choice for you and your family. For instance, you probably prefer a white ceramic crown for a front tooth, but your insurance may only cover metal crowns.
Also, most insurance plans often exclude new treatments that they label as “discretionary.” This includes even common treatments, such as implants, porcelain veneers, white fillings, bonding, and whitening. Cosmetic dentistry is not covered.
In addition, dental insurance coverage maximums just haven’t kept up with the times. Back in 1960, a typical annual maximum was one thousand dollars. Fifty years later, it is still approximately one thousand dollars despite inflation and cost of living increases.
For these reasons, you have a choice to make when it comes to your dental care. In many cases, your insurance plan may want you to consider only the least expensive dental procedures, but we believe that you should be able to choose the best dental treatment and materials for you and your family.
Get Answers to Your Questions About Dental Insurance
For more detailed answers about your dental insurance and treatment coverage, schedule an appointment with Dr. Allen or Dr. Neumann by calling our dental office in Pella, IA, today at (641) 628-1121.