A dental insurance plan is a contract between you and an insurance company that, in most cases, is coordinated by your employer. If that’s the case, the insurance company and your employer are responsible for negotiating the details of the plan. Because our office has no control over this contract, we cannot request additional coverage for you.
Common insurance plans
There are several kinds of dental insurance plans. The four most common kinds of plans are:
- direct reimbursement programs
- preferred provider organizations
- capitation plans (also called dental health maintenance organizations)
- and indemnity or “usual, customary and reasonable” plans
Direct reimbursement programs
In direct reimbursement programs, your employer reimburses you directly for part or all of your dental treatment. All procedures and treatment methods are usually covered, and you can see any dentist you choose.
Preferred provider organizations
In a preferred provider organization, you must choose from a group of dentists who have agreed to discount their fees so that they can be a part of the organization.
In a capitation plan (also called a dental health maintenance program), participating dentists are paid a set amount for each patient enrolled in the plan. Dentists are paid this set amount no matter how often you visit them (or don’t visit them) and no matter what kind of treatment you get. This generally means that the more work these dentists do for their patients, the less money they’ll make.
The most common insurance programs are indemnity plans, which are also called UCR programs. UCR stands for “usual, customary, and reasonable.” In these plans, you may choose any dentist and pay on a traditional fee-for-service basis. The insurance company, who is paid a monthly premium by your employer, then reimburses you for between 50 and 80 percent of the dentist’s fee. You are responsible for the remaining 20 to 50 percent after meeting a pre-determined deductible payment. The amount of the deductible is set in the contract between your employer and the insurance company.
Referring to the program and its fees as “usual, customary, and reasonable” is misleading. Most people assume that insurance companies have gathered statistics and that these statistics are the basis for UCR fees. This is simply not true in many cases. These UCR fees often do not represent local dentists’ fees or the available treatment options. They may be, in fact, simply fees that are set by the insurance company. As a result, different insurance companies often have different UCR fees for the same geographic area and for the same group of dentists!
Behind the times
The annual limit of dental insurance benefits has hardly budged in forty years. Back in 1960, the average annual coverage maximum was one thousand dollars. Forty years later, it still sits at approximately one thousand dollars, despite inflation and cost of living increases.
The benefits have remained the same, but fees for procedures have tripled or even quadrupled. And most insurance plans often exclude new treatments they can label as “discretionary,” including common treatments such as implants, porcelain veneers, orthodontic treatment, bonding, and whitening.
The choice is yours
If you were to build a house, would you rather have the least expensive contractor who used the cheapest materials and technologies? Or would you rather build a home that will last using quality materials?
You have similar choices when it comes to your dental care. In many cases, your insurance company wants you to consider only the cheapest dental procedures, but we believe that you should be able to choose the best dental treatment and materials for you and your family.