Dental benefits usually are provided under a contract between your employer and an insurance company, sometimes referred to as a third-party carrier. Generally you are reimbursed for treatment expenses according to the insurance plan selected by your employer. Other benefit programs may be employer funded, such as a Direct Reimbursement plan.
There are various types of dental insurance coverage options available so it is important that you understand your plan’s limitations and benefits. Unlike diseases of the rest of your body, problems that affect your oral health usually are preventable, making catastrophic dental coverage generally unnecessary. Ask your employer for your coverage information and bring it with you to your dental visit, so that the dental staff can assist you in submitting your benefit claim.
Some plans have not kept pace with advances in dentistry, so you may find certain common procedures excluded or severely limited. Also, a plan may allow the insurance company to substitute a cheaper service that, in the carrier’s opinion, is professionally adequate. In general, rates go up to reflect rising costs, increased use of benefits, or an increase in the fee charged by the insurance company. Employers sometimes reduce your benefits to postpone rate hikes.
Understandably, people make health care decisions based on how much their coverage pays, assuming insurance will always take care of basic needs. Since this is frequently not the case, preventive measures and needed work are postponed. Don’t do it. Prevention is the most efficient and least costly way to protect your oral health. Once dental disease develops, it will not heal without treatment.
WHAT TO LOOK FOR IN A DENTAL BENEFIT PLAN
A Prevention-Oriented Program
A good dental plan should include 100 percent coverage for all diagnostic and preventive procedures. Any dental plan should respect your right to choose your own dentist.
The Doctor/Patient Relationship
People stay with a dentist whose skills they know and trust. The relationship between a dentist and a patient is threatened as new programs are designed to make group coverage less costly for employers. In some cases, the new policies don’t cover treatment provided by your family dentist. You are the best judge of dentists. Neither an insurance company nor your employer knows your individual preferences or needs. They should not choose your dentist for you.
Your Best Interests
Your coverage may be negotiated by administrators whose primary concern may not be your family’s dental needs. Have you ever wondered how your reimbursements are determined? Who judges the appropriateness of treatment agreed to by you and your dentist? Where is that person located? Does that person have the dental training and education to make such decisions?
Your Influence As A Consumer
No matter who pays for your dental benefits, you have a right to be heard. Dental coverage, like salary and vacation time, is part of your total compensation package. exercise your right. Discuss your concerns. Voice your preferences. Any reasonable employer will listen.
WHAT CAN I DO?
Read Your Benefits Booklet
Current federal law requires your plan sponsor to provide a full disclosure and description of your benefits package upon your employment or enrollment into the program. read it!
Once you’ve read your booklet, ask questions on anything you do not understand. If your benefits manager cannot answer your questions, call the insurance company. If you still can’t get answers, you may want to talk to someone at the California Department of Insurance. It has a consumer hotline: 1-800-927-4357. If your coverage is valid only at employer-specified dentists or through service corporations such as Delta Dental or Blue Shield, you will need to contact the State Department of Corporations in Sacramento, rather than the Department of Insurance.
If you receive payment from an insurance company that is less than you expected, talk to your benefits manager and/or the insurance company about your concerns. You have the right to know how your benefits are calculated.
Know the Facts
Insist on a clear description of your dental coverage. Know the different levels and their limitations. To take advantage of your benefits, you may have to stop seeing your family dentist.
Do Your Homework
Insurance companies can create plans that satisfy both your needs and those of your employer. Ask your friends who work in other industries and companies about their benefits. Compare your plan to theirs. Get information about programs you like and pass it along to your benefits manager or your supervisor. Talk to fellow employees about options. A fringe benefit that isn’t used because it doesn’t meet your needs wastes your employer’s money. Speak up!
Draw Your Own Conclusions
What an insurance company pays on claims may bear no resemblance to the average dental fees in your community. Insurance companies can set rates which may not relate to actual costs. Consider that individual dentists’ fees vary due to differences in training, overhead, location and the time required to perform procedures. If your claim was not paid in full, find out why. And if you do not agree, with the insurance company, challenge the reimbursement in writing. It’s your right.