Your exact dental insurance is up to your employer. It is beneficial for helping you to pay for the treatment you need for good oral health. Below, you will find a few common questions and answers about your dental insurance. Please see the Employee Benefits Coordinator at your workplace to discuss your benefits further in depth. Remember that Westmount Dental Centre always explains your available options, discussing with you the benefits and disadvantages of your various options.
Q. Why isn’t my dental treatment fully covered?
A. Most benefit plans do not cover the entire cost of your treatment. There is usually a portion of your bill that is not covered. Any coverage helps to reduce your out-of-pocket fees.
Q. Then why does my plan say that some treatment is 100% covered?
A. The dental insurance carrier allows up to 100% payment of what they think the procedure costs, not what it actually costs. For example, if your dentist charges $80 for an examination, and your insurance allows a payment of $60 as representative of 100% of this treatment, then you must pay the $20 remaining to the dentist.
Q. How does the insurance carrier decide what is an allowed payment?
A. Allowed payments are known as UCR—usual, customary and reasonable. UCRs are covered procedures that have been negotiated between your employer and the insurance company. The UCR listing depends upon the cost of premiums and your location. Your UCR payment (or allowed payment) has been selected according to the desirable premium cost to your employer.
Q. Why is the “usual and customary” treatment cost (assigned by my insurance company) usually exceeded by my dentist? Is the dentist charging too much?
A. The usual and customary treatment cost (the UCR) is a negotiated amount between your employer and insurance company. It is usually less and often much less than what dentists in your area charge for a procedure.
Q. Why do my benefits have an annual maximum?
A. Annual maximums limit what an insurance company has to cover each year. Annual maximum levels have not changed over 50 years.
Q. Why aren’t some procedures covered, such as X-rays, cleanings and gum treatments?
A. How many times per year you can have a procedure is covered in your dental insurance plan contract. The number of X-rays, cleanings and gum treatments are often limited because people frequently have these treatments performed.
Q. What if my plan doesn’t pay for treatment, and I disagree?
A. The Employee Benefits Coordinator at your job may be able to advise you in this situation. A patient sometimes is required to send in a claim themselves. Complaints may be lodged with the Canadian Insurance Bureau.
Q. Why does my benefit plan pay for only the least expensive alternative treatment?
A. Just like any business, insurance companies want to save money. You do not have to accept the least expensive alternative as your treatment—some benefit may still be paid toward the more expensive procedure. The dentist can advise what is best for you, but payment is your decision.