I n s u r a n c e    Q u e s t i o n s Should I make dental treatment decisions based on what my insurance will pay? Understandably, people make decisions based on how much coverage they have and assume that their insurance will take care of all of their costs.  Unfortunately, this is often not the case.  Your dentist prefers to discuss treatment plan's advantages and disadvantages with you, independent of the constraints of your insurance policy.  Always insist on the dental treatment best suited for your overall needs. How much does my insurance cover? No insurance plan is intended to cover all of your costs.  Some insurance plans pay fixed amounts and others pay percentages of pre-determined payment limits for each treatment.  Many insurance salesmen claim that participants will be covered up to 80% or more, but they don't emphasize things like fee-schedule limitations and annual maximums.  It is more realistic to expect dental insurance to pay 35-65% of major services.  The amount a plan pays is primarily determined by how much you and your employer paid for your plan. Are most routine dental services covered by insurance? Many routine dental services are not covered by insurance companies.  It is important that you discuss your limits of coverage with your employer and insurance company. What are the most common types of insurance plans? The three most common types of insurance are: Traditional indemnity insurance plans Preferred provider organizations (PPOs) Health maintenance organizations (HMOs) Traditional indemnity insurance plans offer the greatest freedom of choice and the most covered services.  PPOs and HMOs frequently result in less freedom of choice for the patient, fewer covered services, fewer available appointments, and less expensive materials and lab work being used. Who is ultimately responsible for paying my dentist? When you agree to be treated by your dentist, you accept direct responsibility for paying your dentist.  Your dentist works for you, not your insurance company, and he/she may not even be aware of what your particular plan covers.  While his/her staff may assist you in filing insurance forms, he/she can't guarantee any estimated coverage. What does it mean when my insurance company states that my dentist's fees “exceed usual, customary and reasonable (UCR)”? It usually means that your insurance benefits are too low.  If you have a more expensive policy, the insurance company will often pay a higher amount.  Remember, you only get what you and your employer pay for less the profits of the insurance company.  Your dentist has access to the same UCR fee information that the insurance companies use in paying claims, and he/she can discuss any concerns you may have. Can my dentist charge multiple fees for the same procedure? Your dentist may have multiple fees for similar procedures based on such things as the level of skill, care, judgment, time, materials and lab work provided.  Low-premium plans such as PPOs and HMOs may severely restrict the level of treatment that your dentist can afford to provide. Insurance companies would like you to believe that you can get something for nothing, but that is rarely true. Do insurance companies exist to pay for dental care? Insurance companies exist only to make a profit.  While insurance premiums have gone up over the past 30 years, the average annual insurance coverage is still the same as it was 30 years ago.....$1000.  If you factor in inflation, your insurance benefits should be over $4500 a year!  The insurance company gives you less coverage and charges you more for it. How should I handle problems or concerns with my dental benefits? First, check your benefits booklet.  Next go to your employer's benefits office.  Finally, you may wish to contact the Insurance Commissioner's office in your state.