Your Dental Benefits: What You Should Know

Dental benefit plans are designed to share the cost of dental care. While most plans potentially cover 50 percent or more of the cost of dental services, your plan may not cover the total cost of your treatment.

Dental benefit plans are not really insurance in the traditional sense but are designed to provide you with assistance in paying for your dental care. A plan may have limitations on the number of office visits, consultations, X-rays and various treatments it will cover.

"Usual, customary and reasonable" (UCR) may be one of the most misunderstood terms used in describing dental benefit plans. UCR plans may pay an established percentage of the dentist’s fee, or what the plan considers a "customary" or "reasonable" fee limit, whichever is less.

Although these limits are called "customary," they may or may not reflect the actual fees that dentists in your area charge. Your explanation of benefits (EOB) may note that the fee your dentist has charged you is higher than the UCR reimbursement levels that the plan offers. This does not mean that you have been overcharged. For example, the benefits company may not have taken into account up-to-date data in determining a reimbursement level. Keep in mind that there is no regulation as to how insurance companies determine reimbursement levels, and companies are not required to disclose how they determine these levels. This results in wide fluctuations.

Your dental plan may not allow benefits for all treatment options, even when your dentist determines that a specific treatment is in your best interest. For example, your dentist may recommend a crown, but your plan may offer reimbursement only for a large filling. As with other choices in life, such as purchasing medical or automobile insurance or buying a home, the least expensive alternative is not always the best option.

Just as with medical insurance, a dental plan may not cover conditions a person had before enrolling in the plan. Even though your plan may not cover certain conditions, treatment may be necessary. Your dental plan may not cover certain procedures or preventive treatments regardless of their value to you. This does not mean these treatments are unnecessary. Sealants, for example, can save you money later. Your dentist can help you decide what type of treatment is best.

© 2017 American Dental Association. All rights reserved. Reproduction or republication is strictly prohibited without the prior written permission from the American Dental Association.

This article is intended to promote understanding of and knowledge about general oral health topics. It is not intended to be a substitute for professional advice, diagnosis or treatment. Always seek the advice of your dentist or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment.

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What To Expect During a DENTAL VISIT

On your first visit, your dentist will take a full health history. On follow-up visits, if your health status has changed, make sure to tell your dentist. Here’s what you can expect during most trips to the dentist.

  • A Thorough Ceaning – a dental hygienist or dentist will scrape along and below the gum line to remove built-up plaque and tartar that can cause gum disease, cavities, bad breath and other problems. Then he or she will polish and floss your teeth.

  • A Full Dental Examination – your dentist will perform a thorough examination of your teeth, gums and mouth, looking for signs of disease or other problems.

  • X-Rays – X-rays can diagnose problems otherwise unnoticed, such as damage to jawbones, impacted teeth, abscesses, cysts or tumors, and decay between the teeth.