Frequently Asked Questions (FAQs)

FAQs and More Details About Your Caring Dentist

Frequently Asked Questions (FAQs)

Most of the FAQs we get from our patients relate to their dental benefits. Understanding your dental insurance plan benefits is not easy so we will do our best to help you. There are many different plans and contracts out there. In most cases, your employer selects your plan and what’s covered or not covered.

Your contract specifies what types of procedures your insurer covers. Even if a procedure is needed from a medical and dental standpoint, your plan still may not cover it. This doesn’t mean that you don’t need the procedure. It simply means that your plan will not pay for it since it is not a covered benefit.

However, it would not be wise to let your covered benefits be your main consideration when it comes to dental work.In fact, when you delay treatment it may grow more severe and more costly in the long run.

We do everything possible to work with your plan. But usually, the Employee Benefits Coordinator at your work is the best person to answer your more specific questions. In the meantime, these FAQs may give you a better idea of how it works.

How come my dental insurance doesn’t cover all the costs of my treatment?

When it comes down to it, Dental insurance isn’t really like typical insurance (a payment to cover the cost of a loss) at all. You can think of it more as a prepaid spending card or a coupon to assist with your required dental care. It’s actually a monetary benefit typically provided by an employer to help their employees offset the cost of common dental treatment. Your employer usually buys a plan based on their budget, the costs per month and the benefits offered. Most plans are designed to only cover a portion of the total cost for the most common services.

But my plan says that my dental exams, cleanings and certain other procedures are covered 100%

This can be confusing since the insurance tells you they are covering it at 100% but the question is 100% of what fee? The problem is that it is usually 100% of what the insurance carrier allows as payment toward the procedure, not what your dentist may actually charge (which could be different and depends on the many factors). For example, let’s say your dentist charges $70 for an exam. Your carrier may allow only $55 as the 100% payment for that exam. That leaves $15 for you to pay.

How does my insurance carrier come up with its’ allowed payments amounts?

Many companies refer to their allowed payments as UCR, which stands for Usual, Customary and Reasonable. Sadly, “usual, customary and reasonable” does not really mean what it sounds like. UCR is actually a listing of payments for all covered procedures negotiated by your employer and the insurance company. This listing is related to the cost of the premiums and also where you are located in your city and state.

Your employer has likely selected an allowed payment or UCR payment they’ve budgeted for the plan’s premium. It may not consider other factors you may see as important. These factors include the patient experience, experience and skill level of doctor. Also, insurers may not care about the quality of materials used in your mouth. Nor do they always take into account the quality of technology, or labs used for any required lab work.

If I always have a balance to pay, what good is my insurance?

Even if your benefit plan does not cover the full cost of the needed treatment, in most cases it likely still pays something. Any covered amount then reduces what you have to pay out of pocket so it still helps!

I received an Explanation of Benefits from my insurance carrier. It says my dental bill exceeded the usual and customary. Does this mean that my dentist is charging more than he or she should?

Remember that what insurance carriers call usually and customary is really just what your employer and the insurance company have negotiated as the amount that will be paid towards your treatment. This does not correlate to the actual cost of quality care. It is usually less than what any dentist in your area focused on providing high-quality dentistry and customer service might actually charge for a dental procedure. It does not mean that your dentist is charging too much if there is a remaining balance to be paid.

Why does my benefit plan only pay towards the cheaper alternative treatment?

In order to save money, many dental plans allow a benefit only for the least expensive method of treatment. For example, your dentist may recommend a composite filling, but your insurance benefit only covers you up to the cost of the cheaper amalgam/silver filling. This does not mean that your have to accept the silver filling. The good news is that some amount will still be paid but more of the fee may be your responsibility. However, always keep in mind that your dentist’s primary responsibility is to recommend what is best for you. The insurance carrier’s primary responsibility is to manage their costs and control payments.

Why doesn’t my dentist participate in-network with my dental benefit plan?

Oftentimes the fees offered to a dentist for participating in-network with these plans is much lower than what the dentist needs to charge in order to manage costs and maintain a superior level of service and standard of care. The main reason certain dentists may still choose to participate in such plans is so they can get a steady flow of patients being referred to them from the insurance companies which helps them keep their schedule booked. Some plans also require that the network dentist observe restrictions to treatments they can offer and many dentists are not comfortable with the insurance company influencing the standard of patient care.

What should I do if my dental insurance doesn’t pay for treatment I think should be covered?

Unfortunately, as your dental care provider, we do not have the power to make your plan pay. Since your insurance coverage is between you, your employer, and the insurance carrier, you could discuss it with your employer’s HR department first and see if they can do anything to help you get it covered. Also speaking to the insurance company yourself as the subscriber can sometimes help. If your insurance still doesn’t pay, you are ultimately responsible for the total cost of treatment.


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