WHY DOESN'T MY INSURANCE PAY FOR THIS?

UCR

(Usual, customary and reasonable)

Under a UCR plan, patients are usually allowed to see the dentist of their choice.  These plans pay an established percentage of the dentist's fee or pay the plan sponsor's "customary" or "reasonable" fee limit, whichever is less.  Although these limits are called "customary", they may or may not reflect the fees that area dentists charge. 

It may also be noted on your bill the fee that your dentist has charged you is higher than the reimbursement level of UCR.  This does not mean your dentist is overcharging you.  For example, the insurance company may not have taken into account up-to-date, regional data in determining a reimbursement level.

WHY?  There is no regulation as to how insurance companies determine reimbursement levels, resulting in wide fluctuation.  In addition, insurance companies are not required to disclose how they determine these levels.  The language used in this process may be inconsistent among caries and difficult to understand.

ANNUAL MAXIMUMS

Your plan purchaser makes the final decision on "maximum levels" of reimbursement through the contract with the insurance company. 

Even thought the coast of dental care has significantly increased over the years, the maximum levels of insurance reimbursements have remained the same since the late 1960's.  Many plans offer higher maximums that are comparable to rising dental care costs. 

PREFERRED PROVIDERS

Your plan may want you to choose your dental care from a list of their preferred providers.  Whether or not you choose your dental care from this defined group can affect your levels of reimbursement.

LEAST EXPENSIVE ALTERNATE TREATMENT

Your dental plan may only allow benefits from the least expensive treatment for a condition.  For example, your dentist may recommend a crown, but your insurance may only offer reimbursement for a large filling.  As with other choices in life - such as purchasing medical or automobile insurance, or buying a home - the least expensive alternative is not always the best option.

PREEXISTING CONDITIONS

Just like your medical insurance, your dental plan may not cover conditions that existed before you enrolled in the plan.  Even though your plan may not cover certain conditions, treatment may still be necessary. 

TREATMENT EXCLUSIONS

Your dental plan may not cover certain procedures, or preventative treatments such as sealants that can save you money later.  This does not mean these treatments are unnecessary.  Your dentist can help you decide what type of treatment is best for you.

IF YOU HAVE A QUESTION REGARDING YOUR DENTAL PLAN, OR A PROBLEM WITH A REIMBURSEMENT LEVEL, CONTACT YOUR EMPLOYER OR INSURANCE COMPANY.

Your dentist, or the financial manager or your dental office, may also be able to help explain dental plan issues to you.

However, your dentist may not be able to answer specific questions about your dental plan, or predict what your level of coverage for a procedure will be.  This is because plans offered by the same employer or written by the same third - party payer can vary according to the contrast involved.

The American Dental Association recognizes the important role dental benefits have played in improving access to dental care for millions of Americans, and is working with insurance policymakers to help set better standards within the industry.

FOR ADDITIONAL INFORMATION REGARDING DENTAL PLANS,

contact the American Dental Association, council on Dental Benefits Programs, 211 East Chicago Avenues, Chicago, IL. 60611 e-mail dentalbenefits@ada.org.