Dr. Paul Perella, DMD
Your Dentist in North Palm Beach


So, you have dental insurance, but do you know exactly what it covers? Most folks don't. It's okay. That's why we are writing this blog.

Dental benefit plans are designed to share the cost of dental care. While most plans can potentially cover 50% or more of the cost of dental treatments, your plan may not cover the total cost. Dental insurance is not like medical insurance where the majority of services are covered and your payment is much lower. Rather, they are designed to provide you with assistance in paying for your dental care...a discount, of sorts.

A plan may have limitations on the number of office visits, consults, X-rays and various treatments it will cover. Here are some commonly misunderstood dental plan terms and features to help you understand why you have dental insurance in the first place.

Usual, Customary and Reasonable (UCR)

UCR may be one of the most misunderstood terms used in describing dental benefit plans. UCR plans reflect an already established percentage of the dentist's fee for a service, or what the insurance plan deems a "customary" or "reasonable" fee limit.  Although these limits are called "customary," they sometimes do not reflect the actual fees that dentists in your area charge.

When you receive an Estimation of Benefits (EOB), you might see the dentist's fee are higher than the UCR fees. This doesn't mean you're getting overcharged. The insurance company may not have taken into account increased costs for services when they decided how much they will reimburse. Keep in mind, there is no regulation as to how insurance companies determine reimbursement levels, and they are not required to disclose how they decide on how much to reimburse. This results in wide fluctuations, that unfortunately, the patient and doctor have no control over.

Least Expensive Alternate Treatment Provisions

Your dental plan may not cover certain treatments your dentist recommends that would be in your best interest. For example, your dentist may recommend a crown, but your plan may offer reimbursement only for a large filling (which can be an alternative to a crown, but not in every situation). Just like buying a home or other important necessities, the cheaper alternative is not always the best option. And you may have to pay more out of pocket to get the recommended treatment done.

Annual Maximum

Your dental plan purchaser (for example, your employer) makes the final decision on "maximum levels" of reimbursement when it negotiates the contract with the dental insurance company. The annual maximum is often based on the amount the employer wants to pay for your dental plan. Despite the fact that the cost of dental care has increased significantly over the years, the maximum levels of reimbursement have not changed much in 30 years.

Preferred Providers

Preferred providers are dentists who have negotiated a fee with a dental insurance plan in order to be listed as a provider who participates in the insurance companies' plan. These fees are discounted from the dentist's UCR fees for services and the dentist must honor the established fees with the insurance plan.

Pre-Existing Conditions

Just as with medical insurance, a dental plan may not cover conditions a person had before enrolling in the plan. While treatment is necessary, your dental plan may not cover certain procedures or preventative treatments regardless of their value to you. This unfortunate clause may force you to pay out of pocket for the required treatment.

Questions? Ask your Human Resources or Call the Insurance Company
Dental office staff may not always be able to answer specific questions about your plan or predict the level of coverage for a particular procedure. Plans written by your employer or the insurance company can vary according to the specific contract that was negotiated.

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