How dental plans work


Dental Services Group (DSG) is a network of over 40 North American laboratories that provides dentists with the best of both worlds: the personal relationship and care of a local laboratory, combined with the technical expertise and full suite of offerings of a national laboratory. West Virginia has two DSG dental labs that have shown their dedication to quality of product and education of technicians, dentists and patients. They are members of the National Association of Dental Laboratories. We are proud to provide this section to promote better communication between patients and their oral healthcare providers.

1. How Dental Plans Work

You’ve seen their portraits everywhere – in your history books, your wallet, even on a mountain! But you’ve never seen their smiles. Maybe that’s because they didn’t have a good history with their dentist. You do. Your dentist understands your personal dental needs. And how to ensure that you keep your teeth for a lifetime of good health and appearance.

So, when you’re looking at a new dental plan, make sure you can still see your own dentist. You see, a lot of plans don’t care about your doctor/patient relationship, and might limit you to one of the dentists in their network. So, choose a plan that lets you stick with your own dentist.

Make sure your plan will let you see your dentist. After all, when you wake up with a horrible toothache or your son’s fallen and chipped his front tooth, you’ll want your insurance to pay for the care, no questions asked. And don’t let them dictate what treatment’s best for your smile. Only you and your dentist know what you need to keep your smile looking its best.

Keep all these things in mind and your smile will shine brightly through countless centuries. And remember to talk to your dentist if you have any questions about dental plan options.

2. Evaluating Your Plan

Which is more important to your dental plan — your family’s dental health or the possibility of “saving” a few dollars on your dental plan? Take this quiz to find out.

  • Can I see any dentist I choose?
  • Can I see a specialist any time my dentist or I believe it is necessary?
  • Can I change my dentist at any time?
  • Am I directly involved, along with my dentist, in choosing the best course of treatment to fit my specific needs?

Did you answer yes to all of the above questions? If not, then you’re probably a member of a restricted dental plan and might want to re-evaluate your current choice.

A restricted plan limits its members in two ways – in the number of dentists they can choose from and the amount of care they may receive.

Many of these plans are based upon providing care per person rather than per procedure. This limits your dentist in the quality of care he can provide you with because he has to consider which treatment options your dental plan will pay for rather than which treatment is best for you. Because of this, many dentists choose not to participate in these plans.

See, when deciding how much care should be provided for each patients, these insurance plans base their estimates on what the “average patient” is likely to need. The problem? There’s no such thing as an average patient.

Responsible dentistry requires your dentist to look at your specific situation and to do what’s best for your dental health. Treating you based on the needs and problems of an undefined “average” patient compromises your dentist’s ability to do so.

The Bottom Line

You should have the right to choose, the right to change dentists, the right to consult a specialist and the right to be treated as an individual patient. You should also have the right to say “no.”

If you lack one or more of these very important freedoms, your oral health is likely to be compromised. Trust and good faith is an integral component in the dentist/patient relationship, and your relationship with your dentist is as important to your oral health as brushing and flossing. And since these restrictions can cause mistrust, they’re bound to have negative consequences on your health.

Talk to Your Dentist

If you have questions about your dental plan, or if you need to make a choice about your family’s dental care, talk to your dentist. The members of the Michigan Dental Association encourage you to discuss treatment options, and to make decisions about your care based on facts and professional recommendations. They’ll help you make the right decision so you and your family can smile on.

3. Finding Dental Plans

If you are looking for a list of dental plans or need more information on insurance companies, you may wish to contact the WV Offices of the Insurance Commissioner to see if the dental plan you select is licensed and approved to operate in West Virginia.   Being licensed is important to you should you ever have to request assistance from the Commissioner.

WV Offices of the Insurance Commissioner
PO Box 50540
Charleston, WV 25305-0540

4. How Dental Fees Are Set

If you’re like most people, you probably don’t pay that much attention to your dental benefit plan. You know you’ve got one, but somehow reading that big book that outlines the details has never made it to the top of your list. Ever wonder what it says?

In a nutshell, it tells you that your employer has contracted with an insurance company to pay for a predetermined portion of your dental care. It also outlines what dental services your employer has agreed to pay for and which dentists you can see.

It’s important for you to read and understand your benefit plan. Keep in mind, though, that your insurance plan might not adequately provide for all of your dental treatment options. Only you and your dentist can decide what treatment best meets your dental needs, so don’t rule out a procedure if your insurance won’t cover it.

How are my dentist’s fees determined?

Your dentist charges you a fee for the actual treatment performed and the time it took to complete, as well as a portion of the office overhead. Your dentist’s overhead includes the cost of having quality staff, state-of-the-art equipment, modern dental materials, current infection control procedures, and continuing education to ensure that your dental team is up-to-date on the latest techniques.

How are my dental benefits determined?

Your benefits depend on the contract your employer has set up with the insurance company. Your employer pays the insurance company a specific premium, which the insurance company in turn uses to pay for your care. The higher the premium your employer pays, the less you will be expected to pay out of your own pocket.

When you’re looking at the description of your dental plan, check carefully to see which services will be fully covered by your insurance and which ones will require you to “co-pay,” or shell out your own cash for some or all of the services.

Most insurance plans use a “usual, customary and reasonable” (UCR) fee schedule to decide what portion of the dental treatment it will pay for.

  • A “usual” fee is the fee that individual dentists usually charge for a specific procedure. This fee varies from office to office.
  • A “customary” fee is the highest fee level your dental plan administrator decides it will pay for a specific dental procedure.
  • A “reasonable” fee is the amount your dentist charges if a procedure has special circumstances that justify a higher fee.

A UCR plan will pay either a set percentage of the dentist’s fees, or its “reasonable” or “customary” fee limit – whichever is less. Because these limits are set by your employer’s contract with the insurance company, they may or may not reflect the actual costs of dental care in your area. If a plan’s “customary” fee limits are unrealistically low, you will end up paying a larger portion of the treatment costs.

Again, the amount of reimbursement depends on the specific dental plan that has been purchased. The insurance company can set limits on the amount paid for any dental procedure. For example, if the plan pays at the 80 percent level, that means 80 percent of the UCR fee as determined by the insurance company, not the actual fee charged by the dentist.

Why is there such a big difference between the amount insurance companies will pay?

There are no standards for determining UCR fees. Even if two insurance plans are housed in the same building and owned by the same company, the plans’ administrators might come up with different UCR rates for the same procedure.

For illustration’s sake, lets say 40 people from your town went to see their dentists on the same day to have a missing tooth replaced and those dentists all charge the same price for the procedure. When the bill arrives, each patient is charged an amount that varies by as much as 136 percent.

That’s UCR rates at work. What you pay depends entirely on your employer’s benefit contract and your plan administrator’s UCR fee structure.

What should I do if I get a letter from my insurance company?

If you get a letter from your insurance company stating that your dentist’s fees are above its UCR rate, talk to your dentist. Your insurance company might have out-of-date information, or might not have considered local factors when it set its fee schedule.

If after talking to your dentist and your insurance company you are still not satisfied, talk to your employer or union to let them know that the mask your dental benefit plan is hiding behind didn’t fool you for a second.