Dental Health Insurance
Understanding Dental Insurance Plans
Predetermination of Costs
Some dental insurance plans encourage you or your dentist to submit a treatment proposal to the plan administrator before receiving treatment. After review, the plan administrator may determine: the patient's eligibility; the eligibility period; services covered; the patient's required co-payment; and the maximum limitation. Some plans require predetermination for treatment exceeding a specified dollar amount. This process is also known as preauthorization, precertification, pretreatment review, or prior authorization.
Annual Benefits Limitations
To help contain costs, your dental insurance plan may limit benefits by the number of procedures and/or dollar amount in a given year. In most cases, particularly if you've been getting regular preventive care, these limitations allow for adequate coverage. By knowing in advance what and how much the plan allows, you and your dentist can plan treatment that will minimize out-of-pocket expenses while maximizing compensation offered by your benefits plan.
Peer Review for Dispute Resolution
Many dental insurance plans provide a peer review mechanism through which disputes between third parties, patients, and dentists can be resolved, eliminating many costly court cases. Peer review is established to ensure fairness, individual case consideration, and a thorough examination of records, treatment procedures, and results. Most disputes can be resolved satisfactorily for all parties.
Key Features to Consider When Selecting a Dental Insurance Plan
In reviewing and comparing dental insurance plans, consider the following when determining whether the coverage will satisfy your dental care needs:
- Does the plan give you the freedom to choose your own dentist or are you restricted to a panel of dentists selected by the insurance company? If restricted to a panel, is your dentist on this panel?
- Who controls treatment decisions -- you and your dentist or the dental plan? Some plans may require dentists to follow the "least expensive alternative treatment approach."
- Does the plan cover diagnostic, preventive, and emergency services? If so, to what extent?
- What routine treatment is covered by the plan? What share of the cost will be yours?
- What major dental care is covered by the plan? What percentage of these costs will you have to pay?
- What are the plan's limitations (a limit to the benefits for a procedure or the number of times a procedure will be covered) and exclusions (denied coverage for certain procedures)?
- Will the plan allow referrals to dental specialists? Will my dentist and I be able to choose the specialist?
- Can you see the dentist when you need to and schedule appointment times convenient for you?
- Who is eligible for coverage under the plan and when does coverage go into effect?
Your dentist cannot answer specific questions about your dental insurance plan or predict what level of coverage for a particular procedure will be. Each plan and its coverage varies according to the contracts negotiated. If you have questions about coverage, contact your employer's benefits department, your dental insurance plan, or the third-party payer of your health plan.