So you just got dental benefits through your employer, hurray! Where do we begin?
Dental Plan Basics
Some individuals purchase their own dental plan, but most have dental benefits through their employer. When your employer chooses your insurance plan, they decide the plan’s cost and how often you use their benefits. Most employers will also deduct a portion of each of your paychecks to split the cost of the insurance premiums.
Although they choose the plan, your employer is not responsible for administering your dental plan. Instead, they enter into a contract with an insurance company who then acts as your dental plan administrator. Your dental plan administrator can answer questions about your insurance coverage and must reimburse you based on the terms of the dental plan contract. For some dental services, payment is based on a cost-sharing arrangement between you and your employer. In these cases, you pay for part of the cost, while the plan pays for the rest.
Your dentist may not be familiar with your specific plan coverage so it’s important to know how your plan works. Always read the information booklet or other materials available from your benefits provider.
Some things you should know about your plan:
- What is covered each year?
- Is there a deductible?
- Is there a total dollar limit on my coverage?
- Can I choose a procedure other than the one my plan covers?
- Will I still be covered if I change jobs?
- How much am I covered for cleanings and X-rays?
- How much am I covered for fillings and root canals?
- What about other treatments like bridges and crowns, dentures and oral surgery?
You should also be aware of your co-payment. Co-payment — also called co-insurance — is the part of the bill you won’t be reimbursed for. Many dental plans have a percentage of the claim amount (typically 20 to 50 per cent) that is not covered by the dental plan.
Can my dentist waive my co-payment?
No — waiving a co-payment is insurance fraud and is against the law. Your dentist could be fined or even lose their license. The claim forms you and your dentist sign state which services were provided and how much was charged. The insurance company pays its share based upon the assumption that you will do the same.
Your Dentist’s Responsibilities
Dentists make their treatment plan based on your dental needs. Sometimes, your dental plan coverage and your treatment plan won’t align. If your dental plan only covers part of the cost of your treatment plan, you’ll need to cover the rest.
Your dentist will take you through your personalized treatment plan and answer any questions you may have. They can also help you understand how much may be covered before you move ahead by submitting a pre-treatment form to your dental benefits administrator. Your benefits administrator will provide you with a “predetermination of benefits”. This doesn’t guarantee that the treatment will be covered by your health insurance plan. But it will show you what services are covered and the limitations of your plan.
Remember that your dentist is treating you, not your dental plan. Read more about your dentist’s obligations according to the Royal College of Dental Surgeons of Ontario.
Your Plan and the Claims Submission Process
Once your dental appointment is over, it’s time to make your payment and submit your claim. The way you submit your claim and get reimbursed depends on:
- whether the dentist submits it for you;
- whether you assign your benefits to the dentist;
- or have the plan pay you directly.
Some dentists accept the assignment of benefits. The assignment of benefits means your insurer pays your dentist directly. The dental claim can be submitted to the insurance company by the dental office. All you need to do is provide the dental office staff with your benefit plan number and/or benefits card. Any fees that are not covered by your plan must be paid by you to the dentist.
There are some dentists who do not accept the assignment of benefits; there are some dental plans that will not allow benefits to be assigned. This means that the plan member (you) will be paid by the insurance company. In both cases, this means you’ll need to pay your dental bill upfront. The dental office can still submit the claim electronically to your insurance provider on your behalf and then you wait to get reimbursed.
Getting reimbursed is much faster than it was years ago. Thanks to electronic claims submission, you can see the dentist on Monday and usually get reimbursement before the end of the week. Also, many dentists accept credit cards, which typically have a monthly billing cycle. If you need complex treatment, speak to your dentist about arranging a payment schedule that allows you to budget for expenses.
Benefits of Non-Assignment
The main benefit of the assignment of benefits is the convenient payment process for patients. However, the ODA opposes the assignment of benefits; instead, we believe that non-assignment of benefits is best.
Why does the ODA oppose something most patients find convenient? Because non-assignment means that patients are more involved in their care and the costs involved.
By being more involved you can:
- Have a better understanding of your dental plan and can use it wisely.
- Evaluate your dental plan and identify parts that could be improved.
- Develop the confidence to discuss fees with your dentist.
- Most dental offices can submit your claim for you electronically as a courtesy. If you need to submit your own dental claim form and need help, your human resources department or your dental plan administrator can assist you.
This article was adapted from the Ontario Dental Association: https://www.oda.ca/visiting-the-dentist/dental-benefits/