Insurance

How dental plans work?

Almost all dental plans are the result of the contract between your employer and an insurance company.  The amount your plan pays is agreed upon by your employer with the insurer.

Your dental coverage is not based on your needs or what your dentist recommends.  It is based on how much your employer pays into the plan.  Employers generally choose to cover some, but not all of the employees’ dental costs.  If you are not satisfied with the coverage provided by your insurance, let your employer know.

Will you honor my plan?

Most likely – we accept all PPO insurance plans and we are in the network with Humana PPO, Cigna Radius, Delta Dental Premier.  If your plan is not listed here, please ask about it our front desk coordinator.

Will my treatment be covered?

This question is impossible to answer with a simple „yes”, „no”, or certain percentage number.  The main variables are: different dental benefit plans, individual needs of the patient, various methods of treatment of the same condition.  In general, your insurance company can calculate the coverage for your treatment taking into account the following factors:

• Levels of usual, customary, and reasonable charges („UCR charges”) – UCR charges are the maximum amounts that will be covered by the plan.  They are calculated by each insurance company based on their own formula and not always are updated frequently enough to keep up with the inflation and increasing cost of healthcare.  UCR charges often do not reflect the actual fees charged by the dentists.
• Annual maximum – This is the largest dollar amount a dental plan will pay during a year. The maximum levels of annual payment limits are negotiated between your employer and the insurance company.  You are expected to pay the copayments and any costs above the annual maximum.
• Preferred vs. „out-of-network” provider – Preferred providers are doctors who agreed to provide the health care services to the insurer’s clients at the reduced rates.  On the contrary – the „out-of-network” providers are those who do not have such agreement.  Most of the dental benefit plans offer lower coverage rates for the services rendered by the „out-of-network” providers, increasing that way patient’s out-of-pocket expense.
• Pre-existing condition – Dental plan may not cover treatments for conditions that existed before you enrolled in the plan.  
• Plan limits – Terms of the benefit plan may restrict number of times it will pay for a specific treatment during a year.  For example: it may pay for a teeth cleaning only twice a year while the patient needs cleaning four times a year.
• Least expensive alternative treatment („LEAT”) clause – LEAT clause stipulates that if there is more than one way of treating the specific condition, the insurance will reimburse the cost of the least expensive one.  The least expensive alternative is not always your best option, hence you should always consult with your dentist before making final decision. 
• Treatment deemed not dentally necessary – Each dental benefit plan has its own guidelines for determination which treatment is dentally necessary.  Treatments not meeting dentally necessary criteria may not be reimbursed.
• Coordination (or nonduplication) of benefits – It pertains to patients covered by more than one dental plan.  The insurance companies require that you inform them about another benefits providers, so they can coordinate the levels of reimbursement.  The total amount of benefits cannot exceed the cost of the received treatment.  Having more than one dental plan does not guarantee that your treatment will be covered in 100% or covered at all.

How do I know how much my treatment will cost?

Our office will request the predetermination of benefits from your insurance carrier.  Their response will determine whether the recommended treatment is covered by your plan and in what amount.  Based on their written approval, you will pay only the required copayment and the reminder of the cost not covered by the insurance.  If your insurer denies the coverage, you will be responsible for the full amount should you decide to proceed with the treatment.