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Dental Coverage for Individuals Explained
by John Henning Dental plan coverage for individuals is not commonly offered because dental needs are highly predictable. For example, you would not pay premiums for your dental coverage if the premiums were more expensive than the cost of the dental treatment you need. Since this is the case, insurance companies would stand to lose money (spend more on benefits than they receive in premiums) on every individual dental plan they write.
There are, however, a few companies that offer a form of dental benefits for individuals. Under these types of plans, an individual pays a monthly fee to a third party in return for access to a list of dentists who have agreed to a reduced fee schedule. Payment for treatment is made from the patient directly to the dentist. The third party acts only in the capacity of matching the individual to the dentist. The dentist receives no payment from the third party other than in the form of referral of patients.
Questions or Concerns About Dental Benefits
Your plan sponsor (often your employer) should be able to explain the individual design features of your plan. Design features to understand include: exclusions, limitations, patient co-payments and annual or lifetime benefit maximums.
The American Dental Association has received numerous questions and complaints from patients regarding their dental benefits. To correct some of this confusion about dental coverage, the following questions and answers are provided by the American Dental Association to help better understand dental benefits. If you have additional concerns or questions, they should be directed to your group benefits department. Your personal dentist may also be able to explain dental benefit issues and options for you.
My dental plan says that it will pay 100 percent for two dental checkups and cleanings each year. However, I just had my first checkup and cleaning, and now the insurance company says I owe for part of the dentist's charge. How can this be?
Plans that describe benefits in terms of percentages, for example, 100 percent for preventive care or 80 percent for restorative care, are generally Usual, Customary and Reasonable (UCR) plans. The administrators of UCR plans set what the plan considers to be a "customary fee" for each dental procedure. If your dentist's fee exceeds this customary fee, your benefit will be based on a percentage of the customary fee instead of your dentist's fee.
Exceeding the plan's customary fee, however, does not mean your dentist has overcharged for the procedure. These plans pay a set percentage of the dentist's fee or the plan administrator's "reasonable" or "customary" fee limit, whichever is less. These limits are the result of a contract between the plan purchaser and the third-party payer. Although these limits are called "customary," they may or may not accurately reflect the fees that area dentists charge. There is wide fluctuation and lack of government regulation on how a plan determines the "customary" fee level.
Who is covered by my dental benefit plan? What does my dental plan cover?
This information should be provided by the plan purchaser, often your employer or union, and by the third-party payers. In order that you and the dentist may be aware of the benefits provided by a dental benefit plan, the extent of any benefits available under the plan should be clearly defined, limitations or exclusions described, and the application of deductibles, co-payments, and coinsurance factors explained to you. This should be communicated in advance of treatment.
Understanding Dental Benefit Plans
Employers and other plan sponsors offer dental benefits for a variety of reasons, including promotion of oral health and attraction and retention of high-quality employees.
Regardless of why the plan is offered, its intent is the same: to help individuals by paying for a portion of the cost of their dental care.
Almost all dental benefit plans are the result of a contract between the plan sponsor (usually an employer or a union) and the third party (usually an insurance company). For this reason, concerns about your dental plan should first be directed to your plan sponsor. John Henning offers a Dental Plan. Available to Individuals, Families, Small Businesses & Non-Profit Organizations. $19.95 Month. Guaranteed Acceptance. http://dental4less.tripod.com mailto:john77jr@yahoo.com?subject=articlead
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