Understanding Your Dental Benefits

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Dental insurance is a great tool when it comes to cutting down out-of-pocket costs for dental visits. Due to privacy limitations, however, the information about your plan available to your dental provider is extremely limited. It is important for you to understand the limitations of your benefits and discuss any financial concerns with your provider ahead of treatment.


As each insurance company offers many different plans, there are a few things to keep in mind when finding out about your benefits.


  1. Benefit Plan Maximum: Majority of dental plans have a maximum benefit amount that they will pay out per benefit year. This is usually a combined maximum shared between Basic (exams, radiographs, hygiene therapy, restorations, etc) and Major (crowns, bridges, dentures, implants) procedures. There are certain plans that allow for separate Basic and Major maximums. There are also dental plans that do not have any monetary restrictions. In most cases when a plan contains orthodontic coverage there is a separate lifetime maximum.


  1. Coinsurance and Fee Guides: Your dental plan may have coverage at 100%, 90%, 80% or even lower. Certain procedures may be covered at different coinsurances as well. For example, you may have Basic coverage at 80% but Major and Orthodontic coverage at 50%. It is also important to understand that there is no set dental fee guide in Alberta. That means that the dental fee guide that your benefits follow is determined by your insurance company, and these are the fees that your benefits will pay out on. As this makes it impossible for a dental office to satisfy every fee guide for every insurance policy, there may be fee differences that occur between what your benefits will pay and what the office charges for a procedure. This means that your benefits cover 100% of your insurance companies fee schedule- not the dental offices fee schedule. The patient is responsible for any fee difference or coinsurance after your benefits have paid.


  1. Frequency Limitations: Your plan has limitations on how often procedures will be covered. For example, you may be allowed a routine recare examination every 6 months (or 9 or 12 months), but a new patient comprehensive exam may only be covered once every three years. For scaling or root planing (treatment provided by your hygienist) you are allowed a certain number of units (1 unit=15 minutes) per 12 rolling months. In most cases, the same surfaces of a tooth will only be covered for a restoration once every 2 years.


  1. Age Limitations: Some benefit plans place age restrictions on certain procedures such as fluoride treatment or orthodontic procedures. Many dependent children are covered until age 18 or 21, and may even be eligible as a full time student until age 25.


If you have concerns as to whether or not a procedure will be covered under your benefits, ask your dental provider to submit a pre-authorization to your plan. It normally takes between 2-6 weeks (procedure dependent) to receive a response. Keep it mind that majority of insurance plans will only send their response to the policy holder. Please share this information with your dental provider so that they can insure that you understand all costs and limitations associated with your procedure. Also, a pre-authorization does not guarantee payment; you must also take in account what is left on your plan maximum. Any costs of a procedure that has been pre-authorized but is not covered by your benefits due to a monetary limit becomes the responsibility of the patient.


Remember: it is a courtesy of your dental provider to accept assignment of benefits from your insurance company. Although we may try to the best of our abilities, it is unrealistic to expect the dental provider to keep track of any frequency limitations, or benefit maximums that you may have.