Dental insurance can be confusing. And to make matters worse, every insurance plan handles things differently.
Dental insurance plans are a contract between you and your insurance provider. It is important that you read your insurance policy or talk to your insurance representative so you can understand how your plan helps pay for dental treatment.
Even though most plans pay only for basic services, we believe that you should be able to choose the most appropriate dental treatment for you and your family.
How insurance plans determine payment
Some plans pay only for dentists who belong to the plan’s network, while others let you see the dentist of your choice.
To determine how much they pay for dental treatment, insurance plans use several methods. One is called the Table of Allowances in which the plan lists the treatments it pays for and the amount it pays for each.
Another very common method is called UCR. This stands for “usual, customary, and reasonable.” In these cases, the plan calculates a maximum amount allowed for a particular treatment, and then pays 50 to 80 percent of that amount. You pay 20 to 50 percent of the remaining UCR fees, plus the difference between the actual cost of the treatment and the insurance plan’s UCR fees.
Payment methods not based on statistics
Many people assume that insurance companies base their fees on statistics. However, while statistics are gathered, insurance companies are not required to use them, and sometimes the statistics are out of date. This means that an insurance plan’s UCR fees are usually not representative of what local dentists actually charge.
In fact, different insurance companies’ dental plans often have a different set of UCR fees for the same geographical area and for the same group of dentists. And it is not unusual for the same insurance company to pay different UCR fees to the same dental office, depending on which of the company’s plans the patient is enrolled in.
The choice is yours
You should know that most insurance plans have not kept up with advances in dentistry. They may cover only minimum quality materials and services and exclude treatments they can label as “discretionary.” These often include common treatments such as implants, white fillings, bonding, fluoride treatments, and some periodontal care.
In addition, dental coverage maximums have not kept up with the times. In 1960, a typical annual maximum benefit was $1,000. These days, many plans still offer that same maximum, but to stay up with inflation, that $1,000 in 1960 would have had to increase to more than $6,500 dollars today.
For all these reasons, it is common for our patients to choose a dental treatment that their dental insurance plan does not fully pay for. We urge you to choose the best treatment for you.