Dental Insurance Coverage

Dental insurance coverage can vary in policy limits, deductibles, and financial reimbursement limits. There are a few items to spotlight as you are looking over your policy or considering a new one altogether.

Routine Coverage

Preventative maintenance of your teeth – like cleanings, x-rays, and fluoride treatments – help keep teeth healthy and prevent problems. Therefore, these services are considered valuable and often receive dental insurance coverage at 100%, sometimes after requiring you to a pay a percentage each year. For example, during the first year of dental insurance coverage, the company pays 70% and you pay 30% of the total cost of preventative maintenance. The next year, the company pays 80% and you pay 20% of the total cost as long as you continue to get an exam and cleaning every six months. The pattern continues until the dental insurance company is paying 100%.

Usual, Customary and Reasonable

The term “usual, customary and reasonable”  (UCR) can be a misleading term.  Dental insurance coverage may use this term to determine the portion of the dental treatment fee they will pay based on a standardized chart they have created. UCR reimbursement levels are determined by different methods by the dental plan administrators. They may vary a great deal among dental insurance companies and their plans — even when those plans operate in the same area.

The fee the dental insurance company determines to be “customary” may be very low compared to the area’s average professional fee for the same services. The plans then generally pay a certain percentage of the UCR level. The patient may then be required to pay a greater portion of the treatment costs.

Annual Benefit Cap

Dental insurance coverage also varies in what they pay above and beyond preventative dental care services. It’s not unusual for dental insurance companies to limit the amount of money they’ll pay for dental services in a given year.

If there is a dental issue that requires long-term care, check with your insurance company regarding what they will pay. Some companies operate a sliding scale, such as covering 100% for preventative maintainence, 75% for basic restoration, and 50% for major restoration.

Dental Insurance Deductibles

It’s important to clarify what deductibles you are required to pay before full dental insurance coverage benefits kick in. In addition to UCR and annual benefit caps, an insurance deductible makes a difference in your overall benefits. Research whether the deductible applies per person or per family – the distinction can mean the difference between a small or large out-of-pocket expense.

While dental insurance coverage should be taken into consideration, it should not be the deciding factor in determining your choice of treatment. Dr Beck at South Waterfront Dental will help you make the best decision regarding your dental needs.