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Will this treatment be covered by my benefit plan?2017-09-22T10:23:01+00:00

Commonly Asked Questions

Will this treatment be covered by my benefit plan?

Understanding your dental benefits is not easy. There are as many different plans as there are contracts. Your employer has selected your plan and is ultimately responsible for how your contract is designed. Remember, whether your plan covers a major portion of your dental bill, or only a small amount, dental benefits are good for patients because they help pay for needed treatment.

It is important to know that each contract will specify what types of procedures are considered for benefits. Even if a procedure is medically and dentally necessary, it may be excluded from your contract. This does not mean that you do not need the procedure. It simply means that your plan will not consider the procedure for payment. For example, cosmetic procedures and implants are often excluded from a dental plan. It is a mistake to let benefits be your sole consideration when you determine what you want to do about your dental condition.

Why doesn’t my insurance cover all costs for my dental treatment?

Dental insurance isn’t really insurance (a payment to cover the cost of a loss) at all. It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment. The employer usually buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost.

But my plan says that my exams and certain other procedures are covered 100%.

That 100% is usually what the insurance carrier will “allow” as payment toward the procedure, not what the actually fees for the procedure may be.

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

Many carriers refer to their allowed payments as UCR, which stands for “usual, customary and reasonable”. However, usual, customary and reasonable does not really mean exactly what it seems to mean. 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 where you are located in your city and province. Your employer has likely selected an allowed payment or UCR payment that corresponds to the premium cost they desire. UCR payments could be more accurately called negotiated payments. So the higher premium your employer pays the higher the UCR.

Since the payments are negotiated, does this mean that there is always a balance left for me to pay?

Not always, it will depend on the negotiated contract. For example, some contracts contribute in full and have no annual maximum and others have reductions. You may have 100% coverage but your contract may have limitations built into it that limits the contribution for treatment provided on molar teeth.

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

Even a benefit plan that does not cover a large portion of the cost of needed dentistry it does pay something. Any amount covered reduces what you have to pay out of pocket. It helps!

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

Remember that what insurance carriers call “usual and customary” is really just what your employer and the insurance company have negotiated as the amount that will be “allowed” as payment toward your treatment. It is usually always less or even much less than the suggested “BC General Practitioners Fee Guide” for some dental procedures. It does not mean that your dentist is charging too much.

Why is there an annual maximum on my benefits?

Maximums limit what a carrier has to cover each year and again will depend on the policy selected by the employer and the premium paid each month. Amazingly, despite the fact that costs have steadily increased, annual maximum levels for dental care have not followed suit.

Why does my benefit plan only pay toward the least expensive “alternative treatment”?

To save money, many dental plans allow a benefit only for the least expensive method of treatment. For example, your dentist may recommend a crown, with your insurance only offering a benefit towards a filling. This does not mean that you have to accept the filling. The good news is that some benefit will be paid; the bad news is that more of the fee will be your responsibility. Remember that your dentist’s responsibility is to prescribe what is best for you. The insurance carrier’s responsibility is to control payments.

Why won’t my insurance pay anything toward some procedures, such as x-rays, cleanings, and gum treatments”

Your plan contract specifies how many of certain types of procedures it will consider annually. It limits the number of x-rays, cleanings, and gum treatments it will cover because these are the types of treatments that many people need to have frequently.

I know that my insurance plan doesn’t go into effect until next month. Why won’t my dentist do my treatment today, but send in the claim next month so that the insurance will pay?

Provincial laws regulate these issues. It is insurance fraud to change the dates of service on a claim. Both the patient and the dentist can be prosecuted.

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

Because your insurance coverage is between you, your employer, and the insurance carrier, your dentist does not have the power to make your plan pay. If your insurance doesn’t pay, you are responsible for the total cost of treatment. Sometimes a plan may pay if patients send in claims for themselves. The Employee Benefits Coordinator at your place of business also may be able to help.

Can you help me with my insurance forms? 

Yes we can. We’ll help you understand your insurance coverage, but your benefits package is between you and your employer and may change at any time, so please stay current with your plan and provide us with up to date information so we can make your life easy. We will also help you complete your insurance forms, and can file the forms directly to your insurance company on your behalf. We can even accept payment directly from your insurance company – which makes your life even easier! Contact us to learn more.