The treatments provided to us at the dental office help to prevent infection from starting and spreading, and resolve pain that can be crippling to our quality of life. But while these treatments are important, they aren’t covered by our national health care system. That’s why employer supported health benefits plans play an important role in ensuring you have access to these services.
The insurance companies that provide these coverage plans reimburse patients based on the amount of coverage within the plan.
Health benefits plans classify dental services into three types of coverage:
For each, a variety of plan design features, such as co-insurance, deductibles, and maximums are available.
Basic coverage is table stakes for most plans. It covers treatment for basic diagnostic and preventative services, including routine examinations, radiographs, basic restorations, root canals, cleanings, maintenance of dentures, and extractions.
Coverage for regular cleaning and checkups are described in a plan by ‘scaling units’ and ‘recall’ frequency. Recall describes how often the services around cleanings (exams, polishing, x-rays) are covered – six or nine months being typical. Each scaling unit is equal to fifteen minutes of cleaning with a hygienist, with most appointments for cleaning being three units, but they vary depending on the dental office and individual needs. If you have a dental visit that includes a cleaning, polishing, x-rays, and an exam, the total cost will be applied to your maximum.
Generally, the level of reimbursement for basic services is higher than the percentage reimbursement for Major and Orthodontic Coverage.
Major coverage is seen more often in comprehensive plans. It includes coverages for more extensive and expensive restorative procedures such as crowns, onlays, veneers, bridgework and dentures.
Most dental offices will submit a predetermination to the insurance carrier before doing any work considered 'Major', in order to get an estimate of reimbursement from the carrier based on the treatment plan, x-rays, and diagnosis from the dental office.
Orthodontic services include coverage for procedures and appliances, such as braces, wires, space maintainers and other mechanical aids required to straighten teeth. This coverage is less commonly included in plans, but is a great addition to stand out as an employer.
Any amount in an employee's health spending account can be spent on any service at the dental office that is not strictly aesthetic. These plans provide a ton of flexibility but often give employees access to less dollars for dental treatments.
When you visit the dentist, it's their responsibility to create a treatment plan based on your oral health needs. The work that ultimately gets done should be your decision, and understanding the out of pocket cost will play an important part in it. The price of some services may be high, and each will have their own urgency.
Most dentists are willing to contact a patient's benefits carrier, on a patient's behalf, to find out if a treatment is covered. The majority of offices will charge the insurance company directly for the covered portion, but there are still some that require the patient to pay the full price and submit the claim to the insurer themselves.
In addition to the employee participating in the plan, there is often coverage available for their dependents. To learn more about dependent coverage, check out our previous issue – Who are your dependents? Making sure your family is covered.
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