Understanding Your Dental Benefit Plan & How It Works

What is a dental benefit plan?

A dental benefit plan is a plan that helps patients with the cost of dental care. Most plans are a contract that an employer has with the dental benefit plan company. The benefits that are received are based upon the terms of the contract that have been negotiated between the employer and the benefit plan and NOT the doctors’ office. Not all employers or groups have the same benefits. Not all plans are purchased through an employer/ employee agreement. Individuals that choose to buy a plan independent of their employer would purchase a self-paid benefit plan. We recommend doing research on different plans that may be available to you and those that would suite your needs best.

Covered & Non-Covered Services:

A dental benefit plan covers a variety of services to help you obtain optimal oral health. Because the benefits available are not decided by your oral health needs, there are some services that may not be covered by your dental benefit plan; these services are considered to be a non-covered service. The non-covered services are not based upon what a patient may need or want in order to obtain optimal oral health. It is strictly based upon the contract between the employer and the benefit plan. We do not want to compromise our patient’s oral health based upon what services may or may not be covered. We want the best care for our patients. We suggest that patients read their plan information to familiarize themselves with their specific benefits and those services that are covered or may not be covered.

Pre-Determination Policy:

Some dental benefit plans require an authorization for any treatment the doctor has recommended. Our benefits coordinator will contact your dental benefit plan, as a courtesy to you, to find out if this is a requirement of your plan. In most cases, this is not a requirement of dental benefit plan. If it is not a requirement we will do our best to maximize your dental benefits and let you know your responsibility in advance. Pre-determination of benefits does not guarantee that the dental benefit plan will pay. In the event that your dental benefit plan denies your treatment, you will be responsible for all fees. Naturally, we will always provide you with the estimate of the fees in advance so that you are fully aware of the estimated cost of the treatment prior to utilization of your dental benefits.

Annual Maximums:

Most dental benefit plans have an annual maximum. This is the greatest amount of benefit the plan will pay during your benefit year. The employer and benefit plan decide upon the maximum, along with the percentage of benefit the plan will contribute. When services are covered at a percentage of the allowed amount your responsibility is called a co-payment. As a patient you are expected to pay your co-payment and any costs that may go above and beyond your maximum at the time of service. Once your maximum has been reached, no other services will be covered by your dental benefit plan, regardless how essential the services may be to your oral health.

Preferred Providers:

When you have a dental benefit plan, it is recommended by the benefit plan that you see preferred providers within that network. What this means is that the provider has a contract set up with the dental benefit plan to help patients with the cost of dental care. There are may be circumstances where you may not be able to see a provider who is a preferred provider. This does not mean that you will not be receiving the best care possible. This just means that you may encounter a higher out of pocket expense for your treatment. We suggest patients to read their benefit plan booklet to familiarize themselves with which providers are in or out of network with their benefit plan.

Pre-Existing Conditions:

A dental benefit plan may have restrictions for services for any conditions that may have existed prior to the patient being enrolled in their current benefit plan. This is called a “pre-existing condition”. An example of this would be, “a missing tooth clause”. This states is that if a patient were to seek treatment to replace a tooth that may have been extracted or missing prior to enrollment in their current benefit plan the plan may deny treatment due to the fact that the tooth was already missing before the effective date of the coverage. Even though your plan may not cover certain conditions, you may still be in need of treatment to keep your mouth healthy.

How our office helps:

Our office will do everything we possibly can to help you with your oral health needs. We realize that dental benefits are complex and can be extremely difficult to understand. That is why we provide full assistance to you as a courtesy. We will do our best to help you utilize and maximize your benefits for any treatment you may need.

Our office will complete and submit a claim for services to your dental benefit plan to help achieve maximum reimbursement for which you are eligible. We will work diligently to make this happen as quickly as possible for you.

Please be aware there are times in which we may need to submit to your major medical insurance prior to your dental benefit plan. This is why we ask for all of your information prior to your appointment to allow us to be able to maximize your benefits. We would like to inform our patients that some dental benefit companies take a little longer to process reimbursement. If necessary, our office will contact the benefit plan to expedite the reimbursement.