The number of employers offering dental care insurance is increasing rapidly, as coverage for dental care is being offered more frequently as part of group health plans. Occasionally, dental insurance is part of a health benefits package with a single deductible called an integrated deductible, applying to both medical and dental expenses. More often, dental coverage and dental claims are handled separately, though they may be part of a larger package with a separate deductible for health insurance coverage and for dental insurance coverage. There also may be a probationary period in group dental insurance to help hold down coverage for preexisting conditions.
Some dental policies are scheduled; that is, benefits are limited to specified maximums per procedure, with first dollar coverage. Most, however, are comprehensive policies that work in much the same way as comprehensive medical expense coverage.
In addition to deductibles, coinsurance and maximums may also affect the level of benefits payable under a dental plan. Coinsurance percentages may apply to reimbursements that are either the reasonable and customary (R&C) type or the scheduled type. A plan based on R&C will apply coinsurance percentages to the dentist’s usual and customary fee, provided it is reasonable. This type of plan is also known as usual, customary, and reasonable (UCR) or usual and prevailing (U&P). A plan that is scheduled will apply coinsurance percentages to a schedule or list of fixed-dollar amounts for each covered benefit. Scheduled benefits are generally lower than R&C allowances.
Comprehensive dental plans usually provide routine dental care services without deductibles or coinsurance to encourage preventive dental care. Generally, there is a specified maximum dollar amount payable per year and, sometimes, per family member covered. There also may be a lifetime maximum per individual.
Non routine dental care includes the following:
o Restorative-repairing or restoring dental work that has been damaged in some way
o Oral surgery-surgery performed in the oral cavity, for example, the removal of wisdom teeth
o Endodontics-treatment of the pulp (the soft tissue substance located in the center of each tooth)
o Periodontics-treatment of the supporting structures of the teeth
o Prosthodontics-artificial replacements
o Pediatric dentistry-patient management and preventive and restorative techniques particularly suited to children and adolescents
o Oral pathology-microscopic analysis of tissue biopsy material for diagnosis of oral diseases including oral cancer
o Orthodontics-correction of irregularities of the teeth; most commonly, braces
For non routine treatments, a comprehensive policy pays a percentage, such as 80%, of the reasonable and customary charges. The patient pays an annual deductible and whatever expense remains. Typically, the deductible is per person or per family and most policies limit benefits to stated maximums per year.
Policies that provide for orthodontic care generally have separate limits and deductibles for orthodontia. The coinsurance percentage is likely to be 50% rather than the higher 75% or 80% that applies to other types of non routine dental care.
Many plans offer a selection of providers from which plan participants must choose. In some plans, if a course of treatment is expected to exceed a certain amount, say $200, a report must be submitted to the insurer by the dentist. The report describes the proposed treatment and itemizes the expected charges. The insurer reviews and evaluates this report and sends the dentist an estimate of benefits to be paid.
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