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Dental insurance isn't really insurance (a payment to cover the cost of a loss) at all. It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment. The employer usually buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost.

That 100% is usually what the insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge. For example, say your dentist charges $80 for an examination (not counting x-rays). Your carrier may allow $60 as the 100% payment for that examination, leaving $20 for you to pay.

Many carriers refer to their allowed payments as UCR, which stands for usual, customary and reasonable. However, usual, customary and reasonable does not really mean exactly what it seems to mean. UCR is actually a listing of payments for all covered procedures negotiated by your employer and the insurance company. This listing is related to the cost of the premiums and where you are located in your city and state. Your employer has likely selected an allowed payment or UCR payment that corresponds to the premium cost they desire. UCR payments could be more accurately call negotiated payments.

Typically there is always a portion that is not covered by your benefit plan.

Even a benefit plan that does not cover a large portion of the cost of needed dentistry pays something. Any amount covered reduces what you have to pay out of pocket. It helps!

Remember that what insurance carriers call usual and customary is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment. It is usually less and frequently much less than what any dentist in your area might actually charge for a dental procedure. It does not mean that your dentist is charging too much.

Maximums limit what a carrier has to cover each year. Amazingly, despite the fact that costs have steadily increased, annual maximum level for dental care have not changed since the 1960s. Why do some benefit plans require me to select a dentist from a list? Usually the dentists on the list have agreed to a contract with the benefit plan. These contracts have restrictions and requirements. If you choose a dentist on the list, you typically will pay less toward your dental care than if you choose a dentist not on the list. If your dentist is not on the list this does not mean that something is wrong with the dentist or the office.

To save money, many dental plans allow a benefit only for the least expensive method of treatment. For example, your dentist may recommend a crown, with your insurance only offering a benefit towards a filling. This does not mean that you have to accept the filling. The good news is that some benefit will be paid; the bad news is that more of the fee will be your responsibility. Remember that your dentist's responsibility is to prescribe what is best for you. The insurance carrier's responsibility is to control payments.

Your plan contract specifies how many of certain types of procedures it will consider annually. It limits the number of x-rays, cleanings, and gum treatments it will cover because these are the types of treatments that many people need to have frequently. I know that my insurance plan doesn't go into effect until next month.

State laws regulate these issues. It is insurance fraud to change the dates of services on a claim. Both the patient and the dentist can be prosecuted.

Some plans require that the network dentists observe restrictions to treatment. Many dentists are not comfortable with this.

Because your insurance coverage is between you, your employer, and the insurance carrier, your dentist does not have the power to make your plan pay. If your insurance doesn't pay, you are responsible for the total cost of treatment. Sometimes a plan may pay if patients send in claims for themselves. The Employee Benefits Coordinator at your place of business also may be able to help. Consumers (patients) may also lodge complaints with the State Insurance Commission.