Dentists know how important Dental Insurance benefits are to patients. Navigating the muddy waters of the dental insurance world is challenging, and our Grand Dental insurance specialists are happy to answer some of your most common questions.

Why doesn’t my insurance cover this?

There are many reasons why your dental insurance may not provide complete or any payment for services. Many patients are under the misconception that insurance pays almost all or 100% of their dental costs. This is not true as most plans merely pay 50-80% of the average total dental fee. Some pay more, others less. The percentage paid by your insurance is determined by the amount you or your employer has paid for coverage or the type of contract your employer has agreed upon with the insurance company. Benefits are not determined by your dental office, but rather the insurance policy. This also holds true for the type of procedures your insurance will cover. Preventative, diagnostic, restorative, major dental, periodontal care, oral surgery, and orthodontics are common sub-categories in your dental insurance policy. How much benefit you receive for these services depends on your insurance plan. A plan that pays 100% of preventative and diagnostic procedures such as cleanings, x-rays, and fluoride may still limit who can receive these services and how often. Fluoride treatments for children might be allowed, but not for adults. A patient who has two routine exams in one year might not receive insurance payment for an emergency dental exam, etc. It is important to thoroughly read through your insurance policy to understand these details. Your dental office’s insurance specialist should be able to help you.

What does “Usual and Customary” or UCR mean?

Sometimes your dental insurance company reimburses your dental provider at a lower percentage than the office’s actual fees. Insurance companies state that the reimbursement is reduced because your dentist’s fee has exceeded the “usual, customary, or reasonable” fee used by the insurance company. This statement gives the impression that any fee greater than the amount paid by the insurance company is unreasonable, or well above what most dentists in the area charge for a certain service. This is misleading and inaccurate. Insurance companies create their own fee schedules, and each company uses a different set of fees that they consider allowable. Each company arbitrarily selects the level they determine to be the usual, customary, and reasonable (UCR) fee. Frequently, the insurance company’s data is 3-5 years old and the fees are set so that the insurance company can net a 20-30% profit.

Unfortunately, insurance companies often imply that dentists are “overcharging” rather than admit that they are underpaying or that their benefits are low. In general, a less expensive insurance policy will use a lower usual, customary, and reasonable set fee. Patients who want to receive more benefits from their insurance typically must spend substantially more for the policy and pay higher premiums.

What are deductibles and co-pays?

Deductibles are the amount your insurance company expects you to pay before they pay out any benefit dollars. The deductible is set by your insurance and can be either an individual or a family amount, or both. Co-payments are the amount for which the patient is responsible. Your insurance company sets “co-pay” percentages on dental procedures. These co-pay amounts differ by insurance company and the type of dental service provided. Your co-pay can be as much as 100% of the service, or as little as 0% of the procedure. Your specific insurance plan determines this.

What is “out of pocket” mean?

Your “out of pocket” costs refer to the amount of money you have to pay for your dental treatment. Deductibles and co-payments should be considered when estimating out of pocket expenses. Your out of pocket costs will depend on if you have met your family or individual deductible, what your co-payment percentage for the specified procedure is, the dental provider’s fee, and what your insurance deems as the UCR.

Do you have additional questions about your insurance? Contact our insurance experts today at any of our Grand Dental locations!

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