This information is provided to offer insight and understanding to some of the mechanics in how dental insurance works and how to make it work better for you.
The insurance plan basics explained here reflect what would be considered a high-quality plan, such as is offered by Delta Dental. Such a plan is based on prevention and helps patients establish and maintain good oral health.
The best way to take full advantage of your dental plan is to understand its features. Our best advice is to:
Read your benefits information before you go to your dentist.
Some insurance companies offer a variety of plans with different features. You may have co-workers or friends who are covered by Delta Dental, but may be covered by a different plan or plans offered by the company.
Your dentist may not "participate" in your dental plan. If your dentist does, he or she may submit your claim. If not, you may be responsible for paying your dentist and submitting your claim to the appropriate insurance carrier. If you are entitled to benefits from more than one group dental plan, the amounts paid by the combined plans will not exceed 100 percent of your dental expenses. Benefits for dependents vary from program to program.
Pay particular attention to special clauses and to language about dependents. Dental benefits are calculated within a "benefit period," which is typically for one year but not always a calendar year. Check your benefits information so that you know when you might be approaching your deductible payments or program maximums.
Most dental programs have an annual dollar maximum. This is the maximum dollar amount a dental plan will pay toward the cost of dental care within a specific benefit period. The patient is personally responsible for paying costs above the annual maximum. Again, consult your plan information.
Most dental plans have a specific dollar deductible. It works like your car insurance deductible. During a benefit period, you personally will have to pay a portion of your dental bill before your insurance carrier will contribute to your bill. Your plan information will describe how your deductible works. Plans do vary on this point. For instance, some dental plans will apply the deductible to preventive treatments, and others will not.
Many insurance plans have a co-payment policy. That means the insurance carrier might pay a predetermined percentage of the cost of your treatment, and you are responsible for paying the balance. What you pay is called the co-payment, or out-of-pocket cost. It is paid even after a deductible is reached.
Many dental plans offer three classes or categories of covered treatment. Each class provides specific types of treatment and typically covers those treatments at a certain percentage. Each class also specifies limitations and exclusions (see headings on these elsewhere in this section). Reimbursement levels vary from plan to plan, so be sure to read your benefits information carefully.
Here is the way the three levels typically work:
Class I procedures are diagnostic and preventive and typically are covered at the highest percentage (for example 80 percent to 100 percent of the plan's approved fee). This is to give patients a financial
incentive to seek early or preventive care, because such care can prevent more extensive dental disease or even dental disease itself.
Class II includes basic procedures -- such as fillings, extractions and periodontal treatment -- that are sometimes reimbursed at a slightly lower percentage (for example, 70 percent to 100 percent).
Class III is for major services and is usually reimbursed at a lower percentage (for example, 50 percent). Class III may have a waiting period before services are covered.
Predetermination of Benefits (Estimate of Benefits): If your dental care will be extensive, you may ask your dentist to complete and submit a request for an estimate, sometimes called a "predetermination of benefits." This will allow you to know in advance exactly what procedures are covered, the amount the carrier will pay toward treatment and your financial responsibility.
Limitations and Exclusions: Dental plans are designed to help with part of your dental expenses and may not always cover every dental need. The typical program includes limitations and exclusions, meaning the program does not cover every aspect of dental care. This can relate to the type of procedures or the number of visits. These limitations and exclusions are carefully detailed in plan booklets and warrant scrutiny. These booklets can help you develop realistic expectations of how your dental plan can work for you.