Dental insurance benefits can cause a great deal of frustration for dental patients. Some of the confusing components of dental insurance are explained below.
UCR (Usual, Customary, Reasonable)
Usual, customary and reasonable charges (UCR) are the maximum amounts that will be covered by the plan. Although these terms make it sounds like a UCR charge is a kind of standard rate for dental care, that is not the case. The terms “usual, customary, and reasonable” are misleading for several reasons:
-UCR charges often do not reflect what dentists “usually” charge in a given area.
-Insurance companies can set whatever they want for UCR charges-they are not required to match actual fees charged by dentists.
-A company’s UCR amounts may stay the same for many years-they do not have to keep up with inflations, for example.
-Insurance companies are not required to say how they set their UCR rates. Each company has its own formula.
So if your dental bill is higher than the UCR, it does not mean your dentist has charged too much for the procedure. It could mean your insurance company has not updated its UCRs, or the data used to set the UCRs is taken from areas of your state that are not similar to your community.
Your plan may encourage you to go to a dentist on its list of preferred providers. Some plans allow you to see any dentist you would like, regardless of whether the dentist is on the list. However, your benefits may be different when you visit an out of network dentist.
Some dental insurance plans do not cover conditions that existed prior to enrollment. One example is a “missing tooth clause” which will not pay for the replacement of a tooth that was missing prior to the beginning of coverage. Even though your plan may not cover certain conditions, treatment may still be necessary to maintain your oral health.
Some plans set limits on certain procedures and those procedures may not be covered by your insurance as often as they are dentally necessary. One common example is only allowing for sealants once in a lifetime when sealants generally only last three to seven years. Other patients may need dental cleanings more than the two times per year that their plan allows.
Most plans have a deductible amount which the patient pays before any benefits begin. This is a one-time fee each benefit year. In addition, insurance plans set a percentage of costs they will cover for each type of treatment. For example, an insurance company may cover 100% of preventive work (exams, cleanings, etc.), 80% of basic restorations like fillings and 50% of major restorations like crowns.
Almost all plans will have an annual maximum benefit and many times this amount is as low as $500—$3,000. Patients are often surprised to learn this maximum includes the amount the insurance company paid for preventive check-ups as well. Your plan will not pay more than this set amount in any given benefit year. Patients are responsible for charges above this maximum.
Treatment Exclusion/Wait Periods
Certain plans will not cover some procedures, such as sealants, implants and orthodontics. Dental plans may also place a waiting period on some procedures. For instance, your plan may require you to wait six months for a crown to be a covered service.
Often dental insurance plans will only cover the least expensive treatment possible. For example, many plans only cover the cost of mercury amalgam silver fillings instead of tooth-colored composite fillings. The insurance company will pay its set UCR for an amalgam filling and the patient will pay the difference between the cost of the amalgam and the cost of a composite filling. The least expensive alternative treatment may not be the best choice for optimal dental health. Patients need to choose what is best based upon their needs, not their insurance coverage.
Get the Care You Need
When considering all of this information, it is important to remember that you may need dental care that falls outside of your plan benefits or at a time when you have reached your maximum allowance. In order to avoid future dental complications that could require more extensive (and expensive) treatment later, patients always need to make decisions that are in the best interest of their dental health and seek treatment in a timely fashion.