Dental insurance 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 benefit and how much the premium costs per month. Most benefit plans are designed to cover a portion of the cost.
Why is there an annual maximum on my benefits?
Maximums limit what a carrier has to cover each year.
How does my insurance carrier come up with its allowed payments?
Carriers refer to their allowed payments as UCR, which stands for usual, customary and reasonable. UCR is actually a listing of payments for all covered procedures negotiated by your employer with the insurance company. Your employer selects an allowed payment that corresponds to the premium cost they desire.
Your plan contract specifies how many of certain types of procedures it will cover during a year period. It limits the number of x-rays, cleanings and gum treatments it will cover. Your plan allows for certain percentages of basic and major coverage. Remember that even routine care comes out of the maximum amount covered by your insurance carrier each year.
Benefit plan booklets are often difficult to understand. If any part of your plan is not clear to you, contact your Employee Benefits Coordinator or the Human Resource department where you work.
It is important to know that each contract will specify what types of procedures are considered for benefits. Even if a procedure is medically and dentally necessary, it may be excluded from your contract. This does not mean that you do not need the procedure. It simply means that your plan will not consider the procedure for payment.
Our office will work with you to maximize your insurance benefits. However, it is ultimately your responsibility to know what your insurance carrier covers. Your insurance coverage is between you, your employer, and the insurance carrier.