Understanding Dental Coverage

The best way to take full advantage of your dental coverage is to understand its features. Our best advice is to read your benefits information before you go to your dentist.

Plan Basics

  1. Most insurance companies offer a variety of benefit plans with different features. You may have co-workers or friends who are also covered by Delta Dental, but their coverage may differ from yours.
  2. Your dentist may not "participate" in the network for your dental plan. If your dentist does, he or she will submit your claim. If not, you may be responsible for paying your dentist and submitting your claim to Delta Dental or another insurance carrier.
  3. 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. Benefits for dependents vary from plan to plan. Pay particular attention to special clauses and to language about dependents.
  4. Dental benefits are calculated within a "benefit period", which is typically for one year but not always a calendar year. Check your benefits information so that you know when you might be approaching your deductible payments or plan maximums.

Key Concepts

Maximums

Most dental plans have an annual dollar maximum. This is the maximum dollar amount a dental 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.

Deductibles

Most dental plans have a specific dollar deductible. It works like your car insurance. During a benefit period, you personally will have to satisfy 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.

Coinsurance

Many insurance plans have a coinsurance provision. That means the benefit plan pays a predetermined 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.

Reimbursement Levels

Many dental plans offer three classes or categories of coverage. Each class provides specific types of treatment and typically covers those treatments at a certain percentage. Each class also specifies limitations and exclusions (see headings on these elsewhere in this section). Reimbursement levels vary from plan to plan, so be sure to read your benefits information carefully.

Here is the way the three levels typically work:

  • Class I procedures are diagnostic and preventive and typically are covered at the highest percentage (for example 80 percent to 100 percent of the plan's maximum plan allowance). This is to give patients a financial incentive to seek early or preventive care, because such care can prevent more extensive dental disease or even dental disease itself.
  • Class II includes basic procedures — such as fillings, extractions and periodontal treatment — that are sometimes reimbursed at a slightly lower percentage (for example, 70 percent to 100 percent).
  • Class III is for major services and is usually reimbursed at a lower percentage (for example, 50 percent). Class III may have a waiting period before services are covered.

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. This will allow you to know in advance what procedures are covered, the amount the benefit plan will pay toward treatment and your financial responsibility. A pre-treatment estimate is not a guarantee of payment. When the services are complete and a claim is received for payment, Delta Dental will calculate payment based on your current eligibility, amount remaining in your annual maximum and any deductible requirements.

Limitations and Exclusions

Dental plans are designed to help with part of your dental expenses and may not always cover every dental need. The typical plan includes limitations and exclusions, meaning the plan does not cover every aspect of dental care. This can relate to the type or number of procedures, the number of visits or age limits. These limitations and exclusions are carefully detailed in the plan booklet and warrant your attention. This booklet can help you develop realistic expectations of how your dental plan can work for you.

Allowances for some procedures covered under your benefits may be subject to limitation or denial based upon clinical criteria applied by Delta Dental’s licensed dentist consultant staff. We maintain written guidelines for the use of clinical criteria in making benefit determinations. You may obtain a copy of such guidelines for:

  • Basic benefits
  • Crowns, inlays, onlays and cast restoration benefits
  • Prosthodontic benefits

by sending us a request in writing for the specific benefit category or dental procedure range.

The materials provided to you are guidelines used to authorize, modify or deny coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.

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