August 29, 2003
Contact PDA: (717) 234-5941
Understanding Your Dental Benefits Plan
Deciding who will provide dental care for you and your family should be up to you, not an insurance company. Some dental plans, however, do not give you that choice. Insurance companies decide which dentists can treat you and how much care they are permitted to deliver to you and your family.
While all dental insurance plans will cover basic examinations, cleanings and X-rays, the true test comes when there is a condition requiring treatment. A few extra dollars spent per month on extended coverage could be the difference between saving or owing a bundle of money.
PDA members recommend a dental plan that includes basic coverage for the most common dental treatments, such as preventative sealants, crowns, root canals, periodontal treatment and extractions. Look closely at the limitations of your plan to make sure they are reasonable and realistic.
Be certain that the dental plan you pick lets you see the dentist of your choice. You should expect to see your dentist within a reasonable time frame, especially if you are experiencing a problem.
Although the features of individual plans may differ, the most common dental benefits plans can be grouped into the following categories:
- Direct Reimbursement. These programs reimburse you a percentage of the dollar amount spent on dental care, regardless of treatment category, while allowing you to go to the dentist of your choice.
- Usual, Customary and Reasonable (UCR). These plans pay a set percentage of the dentist's fee or the plan administrator's "reasonable" or "customary" fee limit, whichever is less. Limits are a result of a contract between the plan purchaser (your employer) and the third-party payer (insurance company). In a UCR program you can still go to the dentist of your choice. If your dentist's fee is more than the UCR limits, which are widely varied due to lack of governmental regulation, you are responsible for the difference.
- Table or Schedule of Allowance. These programs generate a list of covered services and a corresponding dollar amount. The dollar amount indicates how much the plan will pay for those covered services. Again, if the dentist's fee exceeds the allowance, you are responsible for the difference.
- Preferred Provider Organization (PPO). Contracting dentists discount their fees as a financial incentive for the patients to select their practices. If you continue to see your dentist who is not enrolled in a PPO, you will have a reduction or complete loss of benefits.
- Capitation. Contracted dentists receive a fixed amount of money per enrolled family or patient. In return, the dentists agree to provide specific types of treatment to the patient at no charge, or with a patient co-payment.
About the Pennsylvania Dental
Founded in 1868, the Pennsylvania Dental Association (PDA) is comprised of approximately 6,000 member dentists. It is a constituency of the American Dental Association (ADA), the largest and oldest national dental society in the world. PDA’s mission is to improve the public health, promote the art and science of dentistry and represent the interests of its member dentists and their patients. PDA is the voice of dentistry in Pennsylvania. Learn more about PDA.