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Ingleside Dental Associates | Your Dental Insurance in Macon

Ingleside Dental


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Your Dental Insurance

Why won't my dental insurance pay for my treatment?

You're not alone in asking this question. According to the American Dental Association, "Dental insurance benefits for the most part have remained at the same level for more than two decades, leaving patients to pick up added out-of-pocket costs". Healthcare expenses rise from year to year. With benefits about the same for more than 20 years, it's vital to understand how to maximize those benefits. Most dental practices deal with hundreds of unique plans from scores of insurance carriers. The more you partner with them to maximize your benefits, the more likely your oral health will continue to be a proirity. This makes the process of visiting the dentist a winning combination for everyone. Let's see how dental insurance works.

Maximums, Deductibles, UCRs

Dental plans carry specific annual maximums. Your maximum may or may not be calculated on the calendar year. Annual deductibles apply and will generally be higher for a family than for the insured member alone.

The carrier bases its payment on several factors: (1) Is the procedure dentally necessary? (2) Is it allowable under the plan's stated frequency for the procdure? (3) Is it paid as Preventive, Basic, or Major? (4) What is the UCR for the procedure?

UCR stands for Usual, Customary and Reasonable. UCR is a number determined by the carrier for the average cost for a procedure (usually within the area encompassed by the first 3 digits of the zip code where the treatment was rendered). Your dentist may charge less or more, depending on such factors as the level of training of the dentist and staff, quality of materials used and investments in technology for patient comfort and care.


3 Categories of Treatment:

As a guideline, your benefits typically fall under one of three categories (Note: Actual procedures under each category vary from plan to plan):

Major - crowns, bridges, partials, dentures, root canals

Basic - fillings, extractions, and advanced perio procedures

Preventive - cleanings, dental exams, x-rays, sealants

Dental insurance plans pay less for Major treatment (up to 60% of UCR) and more for Preventive treatment (often 100% of UCR). Some procedures have a stated frequency for how often benefits will be paid. For example, the frequency for Bitewing X-rays may be twice yearly while Full-mouth X-rays may be once every 3 to 5 years.


First Things First

Did you notice that most plans cover Preventive treatment at 100% of UCR. Insurance companies know that patients who regularly visit the dentist and hygienist for periodic exams and cleanings will experience fewer major problems down the road. For the carrier, preventing future major problems is good business.

Consider your mouth and oral health to be your business. When you receive Preventive treatment, you are stretching your "dental dollars" for years to come. Doing so helps you achieve optimum oral health for the lowest out-of-pocket cost. The best way to minimize your cost, pain, and aggravation, while keeping more of your teeth for a lifetime is to make the most of your plan's Preventive Care provisions.


How Does My Employer Fit In?

If your dental insurance comes as an employee benefit, your employer has shopped and negotiated among insurance carriers for a specific dental benefit "package." Thus, a root canal may be considered Basic treatment under one plan and Major treatment under another. For example, one plan may cover sealants through age 18 and another through age 25 if a dependent is a full-time student. For those reasons, your dentist's staff cannot be wholly familiar with each of the hundreds of plans they administer for patients. If your dental benefits have consistently fallen short of what you expect, speak to your employer. Your employer may appreciate knowing how well the plan is working for you and other employees.

But my next-door neighbor has the same insurance!

You and your neighbor may both be insured by Carrier XYZ. But if you work for different employers, chances are slim that your plans are the same. As mentioned above, each employer negotiates a beneift package that works for their specific budget. Carrier XYZ may offer Plan 1 to your Employer for $1500 per year while offering an expanded Plan 2 to your neighbor's employer for $2100. Even employees of the same company don't always have the same coverage, as plans may distinguish between hourly and salaried persons or between management and support staff.

Understanding your dental benefits can be a bit confusing. Hopefully, you are now better prepared to work with your dentist and staff to maximize your benefits. Making the most of your benefits will give you something to smile about!


Macon Dentist | Your Dental Insurance. Brad Roberson is a Macon Dentist.