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Frequently Asked Questions Will my plan cover the care my family will need? This should be a prime consideration and a major motivation in choosing one plan over another. If your employer offers more than one plan, look at the exclusions and limitations of the coverage as well as the general categories of benefits. We can often help by discussing your family's current and future dental needs with you. This can help you decide what type of coverage you need. Who is covered by my dental benefit plan and for what services? This information should be provided in your plan booklet. A good booklet will clearly define the extent of any benefits available to you under the plan. It should describe any limitations or exclusions, how deductables are applied, and how copayments and coinsurances work. It should also specify who is eligible for coverage under the plan and when that coverage is in effect. To serve you better we subscribe to a computerized service which gives us "unofficial" information about your plan to help you estimate what your benefits are. Any remaining questions should be addressed to your benefits representative at work. You can always go to the dentist of your choice. The real question is whether you will have benefit coverage for the treatment you receive if it is provided by a dentist who is not on the plan's list. This depends on contractual agreements between the plan purchaser (often your employer), the dentists on the list and the plan administrator. Under certain contracts, such as a PPO (Preferred Provider Organization) program, patients are given a financial incentive to go to certain dentists but do receive some level of dental benefit, regardless of the treating dentist. Other plans, such as capitation programs, do not provide any benefit coverage for treatment given by "non-participating" dentists. In all instances where this type of plan is offered, patients should have the annual option to choose a plan that affords an unrestricted choice of a dentist, with comparable benefits and equal premium dollars. My spouse and I each have a dental benefit plan. Whose program covers whom? Your program covers you. Your spouse's program covers him or her. You may have additional coverage from each other's programs if they cover spouses and dependents. In no case will the insurance companies pay more than 100 percent of the dentist's charges for treatment even though you are paying them two full premiums for separate plans which might each individually entitle you to more than 50% coverage on a particular procedure. Can we decide whose program covers our children? The primary plan for covering your children depends on the regulations in your state. Most plans use the "birthday rule" (spouse with birthday occurring earlier in the calendar year is primary). Others consider the father's plan primary. The American Dental Association has recognized the "birthday rule" as the preferred method for coordinating benefits, but which rule applies to your family depends on the language in your dental plan documents. If you have two or more potential sources of coverage, check the coordination of benefits language for each plan to determine the benefits available. Third-party payers often request a "predetermination of benefits" on certain treatment plans. Usually this means an insurance company employee (not necessarily a dentist) will review your dentist's treatment plan and determine what benefits your plan will provide. But this predetermination is not a guarantee of payment. There may be a provision in your plan that will deny your normal dental benefit, or reduce the level of coverage if you do not submit the treatment plan for prior authorization. This is a contractual matter between the plan purchaser and the plan administrator and is illegal in some States for many types of insurance plans - but not all. The major concern with such a requirement is that you have to delay needed treatments, risking more damage, pain, and expense, while waiting to get insurance company approval, or you risk losing the benefits for which you have paid your premium. |
Last modified: 05/03/04 |
