Why Doesn't My Dental Insurance Pay for This?

Dental insurance can be a confusing topic and cause patients a great deal of frustration. Dental insurance can make it easier to get the treatment you need; however, few dental insurance plans cover all the procedures you may require. In general terms, dental insurance is the opposite of medical insurance. With medical insurance, you pay for the small things, and the insurance company pays for the big disasters. Dental insurance is arranged so that they pay for the small procedures and you pay for the big things.

How Dental Plans Work

Most dental insurance plans are a contract between your employer and a dental insurance company such as Delta Dental, Cigna, or MetLife. The type of insurance and the amount of coverage your plan provides is negotiated and largely based on how much your employer wants to spend to provide benefits to their employees.  

Cost-Control Methods

Another way that dental insurance companies control their costs is through UCR, Usual, Customary, and Reasonable Charges. The UCR fee for a certain procedure is the maximum amount your insurance company judges a procedure is worth. Unfortunately, the insurance company can set the UCR amount at whatever they want, and that does not often match what current actual fees are.

UCR fees are set at one rate, no matter if the dentist is a specialty provider or a general dentist and does not take into consideration the additional fees for more complex treatments. Each insurance company has its own formula to determine UCR fees, and they are not required to disclose their methods or formulas.

Levels of Coverage

In general, your dental procedures are categorized into types of services, and each one has a different level of coverage. Preventive services such as cleanings and exams are often covered completely. Basic restorative treatments are usually 75-80% covered, and major restorations drop down to about 50% coverage. Cosmetic services are usually not covered by dental insurance because they are not considered to be medically necessary.

Benefits of Dental Insurance

Those who get the most benefit from dental insurance are patients who don’t need a lot of treatment. Most policies do a good job at covering preventive services and maybe a little more. Keeping current on your six-month checkups and cleanings and a strong home-care routine is the best way to keep your treatment needs to a minimum and reap the benefits of your dental insurance policy.