- 9 Things Dental Insurance Companies Don’t Want You To Know

- 9 Things Dental Insurance Companies Don’t Want You To Know -

Dental insurance does not work like medical insurance!

Many people mistakenly believe that dental insurance works the same way as medical insurance. Most people acquire dental insurance as sort-of a “freebie” or add-on at work. Almost all dental insurance policies, however, have a relatively low cap on how much they will pay, which ...many times is around $1,000 – $1,500 per year. It is also important to understand that typical dental plans cover minor procedures at a higher percentage of reimbursement than the more involved dental treatments. In the best case scenario, insurance companies may cover yearly check-ups and cleanings at 80%-100%; minor dental work like fillings at around 70%-80%; and other dental work 40%-50%. If dental insurance really only provides substantial coverage for smaller procedures, should you let that limit your dental needs and getting the smile you have always wanted and deserve?

Watch out for one of the most commonly used insurance acronyms: “UCR” – Here’s what it really means:

If you ever ask an insurance company how much of a dental procedure will they cover, they will typically respond: “with a certain percent of (for example, 50%) or UCR.” The question is, however, what exactly does that mean? “UCR” stands for Usual, Customary, and Reasonable – which is a favorite phrase of insurance companies, but (with this phrase) lead people to believe that there is some sort of reasonable figure. UCR is really a creature of the insurance company, whereby they develop a schedule of maximum allowable fees for each procedure. This schedule has been mandated by the insurance company, and it’s bench marked with the annual maximum benefit (how much total coverage your policy caps for a year) and the insurance percentage reimbursement schedule (how much of that total is allotted to each procedure), to limit the insurance company’s financial payment on claims. The reimbursement schedule varies greatly on different procedures. For example, one policy may allow over $1,300 for a procedure, while another may only allow $450 on the exact same procedure.

The main three limits on your financial reimbursement:

The major stipulations that limit your insurance reimbursement are: the “UCR,” the Yearly Maximum Benefit, and the Percentage Reimbursement Schedule. They all work together in such a way that it makes it very difficult and a bit confusing to compare policies side by side, for you would have to take all three factors into consideration for each calculation. Of course, this design also benefits these insurance
companies’ sales and the competition amongst themselves. It’s a lot easier to sell a policy while competing with others in the same market, when they don’t have to compete with a well-informed consumer as well. It works in their favor when people can’t easily compare different policies, and most often than not, people purchase dental insurance not truly knowing exactly what’s in their policy or hidden within the “fine print.”

100%, 80%, or 50% Coverage … of what?:

What does it mean when a dental insurance company says they’ll cover 100%, 80%, or 50% of a procedure? What is this calculation based upon? If you think that this means they’ll cover a specific percentage of the dentist’s actual fees, this is not accurate. Remember the UCR? Well, their UCR doesn’t meet even the minimum fees of most dental offices, particularly the good ones and the ones with which you truly want to put your dental health. In fact, their fee limitation may run 50% lower than the dentist’s actual fees. Of course, the actual amount depends on the type of insurance policy itself.

Limited Dental Benefit Plans: The new thing and why you should stay alert:

Be wary whenever you come across dental discount plans and limited benefit dental plans. The reality is that if it sounds too good to be true, it probably is. If you come across any dental insurance plan that seems really great at first glance, be sure to carefully read the fine print and be on the lookout for their UCR and Yearly Maximum Benefit. Quite often actually, the low-cost plans don’t truly save you as much as you think. Even more so, these plans have certain lists of dentists they work with, who have agreed to do procedures at rock bottom prices. This option may work for you if you only buy the cheapest things or go to the cheapest restaurants. But why do that with your oral health? The question you must ask yourself at this point is: what is the knowledge, skill, experience, education, and level of service these dentists have? Also, keep in mind that bigger procedures are usually covered at a minimum, so in the end you still end up paying out of pocket expenses for a dentist that was not your choice to begin with.

Major work equals major waiting periods:

Many people rely on dental insurance plans to offset some of the fees of any major dental work. What the majority of consumers don’t realize by the time it’s too late, is that before any major dental work is covered, the policy usually requires a waiting period, sometimes of up to one year after the person has enrolled in the insurance plan. Also, if there are any pre-existing dental issues, deterioration happens more rapidly, which means that by the time the issue can be addressed, there is a higher risk of even more treatment and a greater expense involved.

Pay attention to the list of excluded treatment – it can often be quite extensive!:

Almost all insurance policies have a list of excluded treatment. Before signing up with any policy you may be considering, make sure to review their list of excluded treatment, since the lists can vary significantly from one policy to another.

Unusually high percentage reimbursement schedules – Too good to be true?:

Don’t be fooled when an insurance company is offering you a very high percentage reimbursement (80%-100%) or a higher yearly maximum benefit. They are aware that consumers are getting more and more educated and knowledgeable, and therefore they will try and make these policies seem like a great deal. But remember what was discussed above. The important question for you to ask is: What is the maximum
allowable fee for each procedure? Usually, they do not clearly stipulate what their fee schedule allowance on these percentages is, or what their yearly maximum is based on. If their maximum allowable is low, regardless of how much percentage is reimbursed (even at 100%), the overall reimbursement will be low. For example, if Policy A reimburses 100% of a procedure, but their allowable fee maximum is $500, then they may be actually paying less in reimbursement than Policy B, that reimburses 50%, but of a $1300 fee schedule allowance on the same procedure. So in the end, Policy B while reimbursing only 50%, will still pay back $650 as opposed to the $500 from Policy A.

Paperwork delays:

Paperwork is never fun, but even less so if you are waiting for dental treatment. Insurance paperwork can be frustrating, especially if the insurance company requires a pre-estimate before they agree to cover the procedure and for how much. Yet, you may be aware that pre-estimates do not even guarantee reimbursement. When you need or want dental treatment or are in pain, this paperwork and delay is truly bothersome. Another frustration of so much paperwork is the ability to clearly make out the estimations of benefit statements and benefit payment records. Many policy holders often express confusion when it comes to this issue. Needless to say, reimbursement or lesser out of pocket expenses is the main reason for having an insurance policy in the first place; and having the ability to clearly discern if the insurance company is paying for the procedures accurately goes right along with it. Yet, you are not 100% clear on the real dental coverage or reimbursement you will receive, it defeats the purpose.
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