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Exactly what is dental insurance for Individuals?

Dental plan coverage for individuals is not commonly offered because dental needs are highly predictable. For example, you would not pay premiums for your dental coverage if the premiums were more expensive than the cost of the dental treatment you need. Since this is the case, insurance companies would stand to lose money (spend more on benefits than they receive in premiums) on every individual dental plan they write.

There are, however, a few companies that offer a form of dental benefits for individuals. Most of these plans are "referral plans" or "buyers' clubs." Under these types of plans, an individual pays a monthly fee to a third party in return for access to a list of dentists who have agreed to a reduced fee schedule. Payment for treatment is made from the patient directly to the dentist. The third party acts only in the capacity of matching the individual to the dentist. The dentist receives no payment from the third party other than in the form of referral of patients.

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My dentist recommends a treatment that my plan will not pay for. Does this mean the treatment really isn't necessary?

It is common for dental plans to exclude treatment that is covered under the company's medical plan. Some plans, however, go on to exclude or discourage necessary dental treatment such as sealants, pre-existing conditions, adult orthodontics, specialist referrals and other dental needs. Some also exclude treatment by family members. Patients need to be aware of the exclusions and limitations in their dental plan but should not let those factors determine their treatment decisions.

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My dentist recommends that I get a crown on a tooth, but my dental benefit will only pay for a large filling for that tooth. Which treatment should I have?

Some plans will only provide the level of benefit allowed for the least expensive way to treat a dental need, regardless of the decision made by you and your dentist as to the best treatment. Sometimes, special circumstances may be explained to the third-party payer to request an adjustment to this lower benefit allowance, but there is no guarantee that the third-party payer will alter its coverage. As in the case of exclusions, patients should base treatment decisions on their dental needs, not on their dental benefit plan.

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My dental plan says that it will pay 100 percent for two dental checkups and cleanings each year. However, I just had my first checkup and cleaning, and the insurance company says I owe for part of the dentist's charge. How can this be?

Plans that describe benefits in terms of percentages, for example, 100 percent for preventive care or 80 percent for restorative care, are generally Usual, Customary and Reasonable (UCR) plans. The administrators of UCR plans set what the plan considers to be a "customary fee" for each dental procedure. If your dentist's fee exceeds this customary fee, your benefit will be based on a percentage of the customary fee instead of your dentist's fee.

Exceeding the plan's customary fee, however, does not mean your dentist has overcharged for the procedure. These plans pay a set percentage of the dentist's fee or the plan administrator's "reasonable" or "customary" fee limit, whichever is less. These limits are the result of a contract between the plan purchaser and the third-party payer. Although these limits are called "customary," they may or may not accurately reflect the fees that area dentists charge. There is wide fluctuation and lack of government regulation on how a plan determines the "customary" fee level.

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Will my plan cover the care my family will need?

This should be a prime consideration and a major motivation in choosing one plan over another. If your employer offers more than one plan, look at the exclusions and limitations of the coverage as well as the general categories of benefits. You should discuss your family's current and future dental needs with your family dentist before making a final decision on your dental plan.

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Who is covered by my dental benefit plan? What does my dental plan cover?

This information should be provided by the plan purchaser, often your employer or union, and by the third-party payers. In order that you and the dentist may be aware of the benefits provided by a dental benefit plan, the extent of any benefits available under the plan should be clearly defined, limitations or exclusions described, and the application of deductibles, copayments, and coinsurance factors explained to you. This should be communicated in advance of treatment.

The plan document should describe the benefit levels of the plan and list any exclusions or limitations to that coverage. This document should also specify who is eligible for coverage under the plan and when that coverage is in effect.

Your dentist cannot answer specific questions about your dental benefit or predict what your level of coverage for a particular procedure will be. This is because plans written by the same third-party payer or offered by the same employer may vary according to the contracts involved. Therefore, you should ask the plan purchaser or the third-party payer to answer your specific questions about coverage.

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My dentist is not on the list of dentists provided by my employer. Can I still go to him/her for treatment?

You can always go to the dentist of your choice. The question is whether you will have benefit coverage for the treatment you receive if it is provided by a dentist who is not on the plan's list. This depends on contractual agreements between the plan purchaser (often your employer), the dentists on the list and the plan administrator. Under certain contracts, such as a PPO (Preferred Provider Organization) program, patients are given a financial incentive to go to certain dentists but do receive some level of dental benefit, regardless of the treating dentist. Other plans, such as capitation programs, do not provide any benefit coverage for treatment given by "non-participating" dentists. In all instances where this type of plan is offered, patients should have the annual option to choose a plan that affords unrestricted choice of a dentist, with comparable benefits and equal premium dollars.

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My spouse and I each have a dental benefit plan. Who in our family is covered by these plans?

Your program covers you. Your spouse's program covers him/her. You may have additional coverage from each other's programs if they cover spouses and dependents. In no case should the benefit derived from the two coordinated programs exceed 100 percent of the dentist's charges for treatment.

The primary plan for covering your children depends on the regulations in your state. Most plans use the "birthday rule" (spouse with birthday occurring earlier in the calendar year is primary). Others consider the father's plan primary. The American Dental Association has recognized the "birthday rule" as the preferred method for coordinating benefits, but which rule applies to your family depends on the language in your dental plan documents.

If you have two or more potential sources of coverage, check the coordination of benefits language for each plan to determine the benefits available.

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Does my dentist have to send a description of my treatment plan to the third-party payer before I have any dental work done?

Third-party payers often request a "predetermination of benefits" on certain treatment plans. Usually this means a dental consultant will review your dentist's treatment plan and determine what benefits your plan will provide. But this predetermination is not a guarantee of payment. You may want to review your benefit prior to receiving treatment, but the final treatment decision should be a matter between you and your dentist, regardless of your benefit.

There may be a provision in your plan that will deny your normal dental benefit, or reduce the level of coverage if you do not submit the treatment plan for prior authorization. This is a contractual matter between the plan purchaser (often your employer) and the plan administrator and is contrary to the policy of the American Dental Association. The American Dental Association is opposed to any dental clause that would deny or reduce payment to the beneficiary, to which he/she is normally entitled, solely on the basis or lack of preauthorization.

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How are benefits determined?

You should know how your plan is designed, since this can affect significantly the plan's coverage and your out-of-pocket expense.

Some employers now offer more than one dental plan to their employees. In fact, the right to choose between two plans could be the law in your state. To understand and make decisions about your dental benefits, it is important to remember that plans are often very different. To make the best decision for you and your family, you should understand exactly how the different kinds of dental benefit plans work and how they derive their cost savings.

There are many ways to design a dental benefits plan. Although the individual features of plans may differ somewhat, the most common designs can be grouped into the following categories:

Direct Reimbursement programs reimburse patients a percentage of the dollar amount spent on dental care, regardless of treatment category. This method typically does not exclude coverage based on the type of treatment needed and allows the patients to go to the dentist of their choice.

"Usual, Customary and Reasonable" (UCR) programs usually allow patients to go to the dentist of their choice. These plans pay a set percentage of the dentist's fee or the plan administrator's "reasonable" or "customary" fee limit—whichever is less. These limits are the result of a contract between the plan purchaser and the third-party payer. Although these limits are called "customary," they may or may not accurately reflect the fees that area dentists charge. There is wide fluctuation and lack of government regulation on how a plan determines the "customary" fee level.

Table or Schedule of Allowance programs determine a list of covered services with an assigned dollar amount. That dollar amount represents just how much the plan will pay for those services that are covered. Most often, it does not represent the dentist's full charge for those services. The patient pays the difference.

Preferred Provider Organization (PPO) programs are plans under which contracting dentists agree to discount their fees as a financial incentive for patients to select their practices. If the patient's dentist of choice does not participate in the plan, the patient will have a reduction or complete loss of benefits.

Capitation programs pay contracted dentists a fixed amount (usually on a monthly basis) per enrolled family or patient. In return, the dentists agree to provide specific types of treatment to the patients at no charge (for some treatments there may be a patient co-payment). The capitation premium that is paid may differ greatly from the amount the plan provides for the patient's actual dental care.

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How should I go about asking my employer to provide a dental benefit plan at our company?

The American Dental Association recognizes the important role dental benefits have played in improving access to dental care for millions of Americans. You or your employer may contact the Association for more detailed information about how employers of all sizes can provide a cost-effective, high-quality dental benefit plan for their employees.

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What is Direct Reimbursement?

Direct Reimbursement programs reimburse patients a percentage of the dollar amount spent on dental care, regardless of treatment category. This method typically does not exclude coverage based on the type of treatment needed and allows the patients to go to the dentist of their choice.

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