Cosmetic Dentistry-Insurance Questions Answered

We know it can be frustrating and sometimes complicated to understand, what is and is not covered under your particular insurance plan. If you do not understand the reimbursement levels on your bill you’re not alone. We are providing the following information to answer some of our patients questions about their insurance coverage.

What is dental insurance?

A dental benefit plan helps you pay for the cost of your dental care. It is a contract between your employer, or plan sponsor and a third party (insurance company) These contracts vary widely. You need to know how your dental plan is designed and it’s limitations. It may not cover the total cost of your bill. Most plans cover between 50 to 80 percent of dental services.

What is a UCR program?

“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. Although these limits are called “customary,” they may or may not accurately reflect the fees that area dentists charge.

There is no regulation as to how insurance companies determine reimbursement levels, resulting in wide fluctuation. So, on your bill the fee that your dentist has charged you may be higher than the reimbursement levels of your UCR plan. This does not mean your dentist is overcharging you.

Factors that influence your reimbursement levels

  • Annual maximums-Your plan purchaser makes the final decision on “maximum levels” of reimbursement through the contract with the insurance company. Even though the cost of dental care has significantly increased over the years, the maximum levels of insurance reimbursements have remained the same since the late 1960’s. Many plans offer higher maximums that are comparable to rising dental care costs. Check with your purchaser.
  • Preferred providers-Your plan may want you to choose your dentist from a list of their preferred providers. Whether or not you choose your dental care from this defined group can affect your levels of reimbursement.
  • Least expensive alternative treatments-Your dental plan may only allow benefits for the least expensive treatment for a condition. For example, your dentist may recommend a crown, but your insurance may only offer reimbursement 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.
  • Preexisting conditions-Just like your medical insurance, your dental plan may not cover conditions that existed before you enrolled in the plan. Even though your plan may not cover conditions, treatment may still be necessary.
  • Treatment exclusions-Your dental plan may not cover certain procedures or preventative treatments, such as sealants, that can save you money later. This does not mean these treatments are unnecessary. Your dentist  can help you decide what type of treatment is best for you.

If you have further questions about dental insurance or any other aspects of cosmetic dentistry please write them in the comments portion of this blog. We will be using this forum to answer our patient’s questions and keep our clients up-to-date on cosmetic dentistry procedures.

Our goal is to provide our clients with  quality and caring cosmetic dentistry services. We look forward to collaborating with you for your dental health.

3 comments on “Cosmetic Dentistry-Insurance Questions Answered”
  1. Steve

    Thanks for the info! This certainly helps answer a lot of the questions I had about my coverage.

  2. Elmore

    I’m wondering if anyone knows of an insurance plan that will (or at least sometimes does) pay for a treatment such as Invisalign. I’d rather not have braces at my age and I’ve heard Invisalign is always an out-of-pocket expense because it’s considered a voluntary procedure. Any info would be helpful, thanks!

  3. Elmore: great question! While many insurance plans cover orthodontic treatment, most have stipulations (such as age, or a set amount like $1000 per insured). Check your plan to see if orthodontics is covered. If not, check with your employer to see if this can be added at some time to your plan. Let me know if you have any luck!

    Greg Pyle

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