DENTAL INSURANCE

DENTAL INSURANCE

Dental plan is the best way to take full advantage of your dental coverage is to understand its features. Best advice is to read your benefits before you go to your dentist.

 BASIC PLANS

 1.    If not, you may be responsible for paying your dentist and submitting your claim to Delta Dental or another insurance carrier. Your dentist may not "participate" in the network for your dental plan. If your dentist does, he or she will submit your claim.

 2.    You may have co-workers or friends who are also covered by Delta Dental, but their coverage may differ from yours.Most insurance companies offer a variety of benefit plans with different features.

 3.    Benefits for dependents vary from plan to plan. Pay particular attention to special clauses and to language about dependents.If you are entitled to benefits from more than one group dental plan, the amounts paid by the combined plans will not exceed 100 percent of your dental expenses.

 4.    Check your benefits information so that you know when you might be approaching your  deductible payments or plan maximums Dental benefits are calculated within a "benefit period", which is typically for one year but not always a calendar year.

 Key Concepts

·           Deductibles

·           Maximums

·            Reimbursement levels

·           coinsurance

·           Pre-treament estimate

·           Limitations and exclusions

 Deductibles

 Most dental plans have a specific dollar deductible. It  works like your car insurance. During a benefit period,  you personally will have to satisfy a portion of your dental bill before your benefit plan will contribute to   your cost of dental treatment. Your plan information will describe how your deductible works. Plans do  vary on this point. For instance, some dental plans will apply the deductible to diagnostic or    preventive treatments, and others will not.

 Maximums

 Most dental plans have an annual dollar maximum. The patient is personally responsible for paying  costs above the annual maximum. Consult your plan booklet for specific information about your plan.

 Reimbursement Levels

 Each class provides specific types of treatment and typically covers those treatments at a certain  percentage. Many dental plans offer three classes or categories of coverage. Each class also specifies   limitations and exclusions .Reimbursement levels vary from plan to plan, so be sure to read your  benefits information carefully. Here is the way the three levels typically work.

·           Class I includes basic procedures — such as fillings, extractions and periodontal treatment  — that are sometimes reimbursed at a slightly lower percentage (for example, 70 percent to  100 percent).  

·           Class II  procedures are diagnostic and preventive and typically are covered at the highest  percentage (for example 80 percent to 100 percent of the plan's maximum plan allowance).  This is to give patients a financial incentive to seek early or preventive care, because such  care can prevent more extensive dental disease or even dental disease itself.

·          Class III is for major services and is usually reimbursed at a lower percentage (for example,  50 percent). Class III may have a waiting period before services are covered.

 Coinsurance

 What you pay is called the coinsurance, and it is part of your out-of-pocket cost. It is paid even after a   deductible is reached That means the benefit plan pays a predetermined percentage of the cost of       your treatment, and you are responsible for paying the balance. Many insurance plans have a   coinsurance provision.

 Pre-Treatment Estimate

 If your dental care will be extensive, you may ask your dentist to complete and submit a request for a  cost estimate, sometimes called a pre-treatment estimate. A pre-treatment estimate is not a guarantee   of payment. When the services are complete and a claim is received for payment, Delta Dental will  calculate payment based on your current eligibility, amount remaining in your annual maximum and    any deductible requirements.This will allow you to know in advance what procedures are covered, the  amount the benefit plan will pay toward treatment and your financial responsibility.

 Limitations and Exclusions

 Dental plans are designed to help with part of your dental expenses and may not always cover every    dental need. This can relate to the type or number of procedures, the number of visits or age limits.  The typical plan includes limitations and exclusions, meaning the plan does not cover every aspect of  dental care. This booklet can help you develop realistic expectations of how your dental plan can work   for you.These limitations and exclusions are carefully detailed in the plan booklet and warrant your        attention.

 We maintain written guidelines for the use of clinical criteria in making benefit determinations.  Allowances for some procedures covered under your benefits may be subject to limitation or denial  based upon clinical criteria applied by Delta Dental’s licensed dentist consultant staff. You may  obtain a copy of such guidelines for:

·                Crowns, inlays, onlays  and cast restoration benefits

·                Prosthodontic  benefits

·                Basic benefits

 by sending us a request in writing for the specific benefit category or dental procedure range.

 Specific care and treatment may vary depending on individual need and the benefits covered under  your contract.The materials provided to you are guidelines used to authorize, modify or deny coverage  for persons with similar illnesses or conditions. 


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