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If you have insurance we all have all wondered why our insurance either doesn't cover something at all or just doesn't seem to cover enough. We recieved a flyer in the mail from the American Dental Association, and I wanted to pass along some interesting news.  

Your dental coverage is not based on what you need or what your dentist recommends. It is based on how much you or your employer pays into the plan. 

How Dental Plans Work: Almost all dental plans are a contract between yourself or your employer and the insurance company. Often, you may have a dental care need that is not covered by your plan. Employers generall choose the cover some, but not all of employee's dental costs. If you are not satisfied with the coverage provided by your insurance, let your employer know. 

The Role of Your Dental Office:  Your dentist's main goal is to help you take good care of your teeth. Many offices will file claims with your dental plan as a service to you. The part of the bill not covered by insurance is your responsibility.

Cost Control Measure used by Dental Benefit Plans:  

               UCR (Usual, Customary & Reasonable) Charges: UCR charges are the maximum allowable amounts that will be covered by the                 plan. Although these terms make it sound like a UCR charge is the standard rate for dental care, it is not. The terms "usual,                 costumary & reasonable" are misleading for several reasons:

                    Insurance companies can set whatever amount they want for UCR charges.  They may not match current actual fees charged                         by dentists in a given area.

                     A company's UCR amounts may stay the same for many years. They do not have to keep up with inflation or the costs of dental                     care.

                    Insurance companies are not required to say how they set their UCR rates. Each company has its own formula.        

            If your dental bill is higher than the UCR, it does not mean your dentist has charged too much. It could mean your insurance             company has not updated its UCR charges. It could also mean that the data used to set the UCR is taken from areas of your state             that are different from yours. 

            Annual Maximums:  This is the largest dollar amount a dental plan will pay during the year. You or your employer decides the                 maximum levels of the payment in its contract with the insurance company. You are expected to pay copayments and any                       costs above the annual maximum. Annual maximums are not always updated to keep up with the costs of dental care. If the annual               maximum of your plan is too low to meet your needs, ask your employer to look into plans with higher annual amounts. 

            Preferred Providers: The plan may want you to choose dental care from its network of preferred providers. The term "preferred"             means these dentists have a contract with the dental benefit plan; it does NOT mean these are dentists the patient prefers. If you get             dental care from a dentist who is not in the network, you may have higher out-of-pocket costs. Learn about your plan's costs when             using both in-and out-of-network dentists.

            Pre-Existing Conditions: A dental plan may not cover conditions that existed before you enrolled in the plan. For example, benefits             will not be paid for replacing a tooth that was missing before the effective date of coverage. Even though your plan may not cover               certain conditions, you may still need treatment to keep your mouth healthy. 

            Coordination of Benefits (COB) or Nonduplication of Benefits:  These terms apply to patients covered by more than one dental             plan. The benefit payments from all insurers should not add up to more than the total charges. Even though you may have two or               more dental benefit plans, there is no guarantee that all of the plans will pay for your services. Sometimes, non of the plans               will pay for the services you need. Each insurance company handles COB in its own way. Please check your plans for details. 

           Plan Frequency Limitations: A dental plan may limit the number of times it will pay for a certain treatment. But some patients may                  need a treatment more often to maintain good oral health. For example, a plan might pay for teeth cleaning only twice a year even                though the patient needs a cleaning four times a year.  Make treatment decisions based on what's best for your health, not just               what is covered by your plan. 

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