Let’s be practical and talk about money. Coming to the dentist is already a complex experience because there are so many factors to deal with and concerns over how to pay for the services is a big one. Knowing how dental “insurance” works will help you decide how to plan your care. We are committed to helping you file your claim, provide the needed documentation, and be your advocate when they give you the run around. It is our best interest to help you, but it not in the insurance companies best interest to pay you quickly.

What is dental insurance?

First of all, what you have is not really an insurance policy. Insurance is a promise of compensation for specific potential future losses in exchange for a periodic payment. Insurance is designed to protect the financial well being of an individual, company or other entity in the case of unexpected loss. So-called dental insurance doesn’t do that at all. It is more accurately referred to as a dental benefit plan and is typically something that is purchased by an employer and offered to an employee as an added benefit to your compensation package. It is essentially a money benefit that can be used to offset the cost of some dental services. The employer and the carrier decide which services or procedures it would like to help towards and how many times per year your employer would be willing to pay you a money benefit for a particular service. For example, most employers decided to pay for two exams a year.

The “insurance carriers” know that almost half of the population doesn’t go to the dentist at all except in the case of an emergency. So, they take the employer’s money in the form of premiums, and half the time they don’t have to give any to the customers (employees) who don’t go to the dentist! That’s a good deal for them.

The generous employer can advertise that “we” offer dental insurance and that helps them recruit people and is in fact another way to increase a person’s total compensation package. It is just another benefit to working there. The employer pays a small premium (average of $250/year) and can provide the employee with a plan that could cover $1500/year. That’s a good deal for both the employer and the employee.

It is good for the dentist because patients can come more often if they have some help paying the bills or at least paying some of the cost.

Why are their yearly limits?

There is a limit to how much the employer is willing to pay to offset your dental care and currently that amount is about $1500 per year for most plans in the “dental insurance” industry. These plans are not like medical insurance where you pay a deductible and then they pay up to hundreds of thousands of dollars.

Why can’t you file my medical insurance?

Many medical policies are written to specifically exclude dental work! Despite the fact that having healthy teeth and gums are obviously an important part of your health and are definitely parts of your body, the fact remains that dental care is rarely covered.

How the money benefit works:

The employer shops the market for dental plans and then picks one based on how much money benefit they want to give each employee. The employer decides how much they want to pay each year and the insurance carrier helps them match up with a plan they offer. Each plan has limits to what it will pay. For example, if the plan your employer bought for you says that it will pay $60 for a dental exam, and then when you go to see the dentist, your plan will pay you $60 after you send in the paperwork proving you had an exam. If the dentist charges $80, then you would have only had to pay twenty of your own dollars for an $80 service. Sometimes the dentist will only ask you to pay the $20 and then will send in the paperwork for you and the carrier then sends the $60 to the dentist. Depending on the reputation of the carrier, a dentist may ask the patient to pay the whole bill and have the carrier pay the patient directly.

Benefit plans may not cover all the costs of your treatment:

Dentists set their fees based on the various factors such as overhead, time involved, and the complexity of the service to be provided. The dentist’s fees have nothing to do with the amount of money that your employer chooses to give to you in the form a dental benefit. For example: Let’s say the money benefit in your plan pays a maximum of $1000 dollars per year and one of the services covered is a crown. The cost of one crown in 2013 is about $1000. In this case, your plan pays you just the right amount so that you won’t have to come “out-of-pocket” at all. However, if you need another crown or any other kind of services, you will not have any benefits left to offset the cost and if you choose to have the service, you would have to pay the fee without help from your employer.

Your plan may say that exams are covered 100%. What does this really mean? From the exam example, it means that the plan will pay up to 100% of the $60 that your employer agreed to pay you as a money benefit, but if the exam cost $80 you would still have to add $20 to what your benefit package paid. If they dentist only charged you $30, the benefit would be $30 and you could not get $30 more in cash from anyone.

Why are there annual limits to your plan?

The answer is simple. Your employer only wants to pay you a fixed amount per year to go towards your dental work. It is interesting that when these dental insurance benefit plans were conceived in the late 1960’s that yearly maximums were around $1000 and that almost 43 years later it is still around an average of less than $1500! Needless to say, the cost of dental services has gone up in 42 years and that makes the actual value of dental “insurance” is less with every passing year. Nevertheless, any amount that someone else pays for your dental work is a good thing.

“UCR” (Usual, Customary, and Reasonable) verses
“Allowed Payments”

This one really makes the dentists mad because the language makes it seem like the fees we charge are not usual, customary, or reasonable! The employer and the carrier agree on how much money benefit they wanted to allow or give you for a procedure and it was referred to as the “allowed payment”. How did it come to be called the usual, customary, and reasonable or UCR? I don’t think you can get an answer to that from anyone in the insurance industry, but I can tell you that the effect of the language leads the patient to believe that the dentist is charging more than what is reasonable and that makes the patient feel ripped off and mad at the dentist who has nothing to do with how much money your employer wants to give you as a dental benefit. If the patient gets mad and delays treatment, it saves the insurance carrier money and that’s for sure. They get to keep the premium the employer paid and don’t have to give any back to the patient. That’s a big win for them and a big loss for you.

Who should know the most about your dental plan?

The Employee Benefits or Human Resources department where you work is the best place to start. It is their full time job to help you understand your plans coverage, do pre-estimates, and get answers from the carrier. Yet it is usually the dental office that really provides this service to you in order to entice you to choose their office. That is a choice a dental office makes, but since your dentist isn’t the customer of the insurance company, they have little influence over the insurance companies. That is why so many dental office administrative staffers are constantly in a bad mood. Patients want us to “do something” to help them and we have NO power to make the insurance company do anything. Staffers who want to help have their hands tied and confused and frustrated patients take it out on them. It is a strange situation. That is why I have spent so much time trying to explain and educate with this document.