Most dental plans have an annual dollar maximum. This is the maximum dollar amount a dental benefit plan will pay toward the cost of dental care within a specific benefit period (usually January through December). The patient is personally responsible for paying costs above the annual maximum. Consult your plan booklet for specific information about your plan’s annual maximum.
Dental benefits are calculated within a “benefit period”. The benefit period typically is for one year, but not always a calendar year. To learn when you might be approaching your deductible payments or plan maximums, you can check your benefits information online at www.deltadental.com.
Categories of Coverage:
Many denta plans offer three classes or categories of coverage – often with different reimbursement levels for each. Each class provides specific types of treatment and those treatmetns are typically covered at a certain percentage. Each class also specifies limitations and exclusions (see specific section below). Procedures within a category of services can vary from plan to plan, so be sure to reach your benefits information carefully.
The three levels typically work this way:
- Class I procedures are diagnostic and preventive. These are usually covered at the highest percentage (for example, 100 percent of the plan’s approval fee). This gives patients a financial incentive to seek early or preventive care because such care can deter dental disease and the need for more expensive treatments in the future.
- Class II includes basic procedures – such as fillings, extractions and periodontal treatment – that are sometimes reimbursed at a slightly lower percentage (80 percent, for example).
- Class III is for major services and is usually reimbursed at a lower percentage (for example, 50 percent). Class III services may have a waiting period before they are covered.
Coinsurance: Many insurance plans have a coinsurance provision. That means the benefit plan pays a per-determined percentage of the cost of your treatment, and you are responsible for paying the balance. 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.
Coordination of Benefits (COB): 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. This is known as coordination of benefits, or COB.
Deductibles: Most dental benefit plans have a deductible - a specific dollar amount you must pay before the plan begins to cover your expenses. During a benefits period, you personally will have to pay 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.
Enhanced Benefits: Many plans now offer enhanced coverage for individuals who have specific health conditions that can be positively affected by additional oral health care. These enhancements are based on scientific evidence and often include additional cleanings and/or applications of topical fluoride for at-risk individuals (for example, individuals with periodontal disease, diabetes, or heart conditions).
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 or pre-determination of benefits. This will allow you to know in advance what procedures are covered, the amount the benefit plan will pay toward treatment your financial responsibility.