Get the most value from your dental benefits plan by understanding the features it offers. Review your plan before visiting the dentist so you can make informed decisions about your care.
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). You are responsible for paying costs above the annual maximum. Consult your plan booklet for specific information about your plan.
Most dental plans have a deductible. This means that during each benefit period (usually one year), you will have to pay a specific dollar amount before your benefit plan contributes to your dental treatment costs. Check your plan booklet to see how your deductible works. Most dental plans do not apply the deductible to diagnostic and preventive treatments, but some do.
Many dental plans have a coinsurance provision. That means your plan pays a predetermined percentage of the cost of your treatment, and you are responsible for paying the balance. What you pay is called "coinsurance," and it is part of your out-of-pocket costs. It is paid even after a deductible is reached.
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 details below). Reimbursement levels vary from plan to plan, so be sure to read your plan booklet carefully.
Here is the way the three levels typically work:
If your dental care will be extensive, you may ask your dentist to complete and submit a request for a cost estimate, also called a pre-treatment estimate. This will allow you to know in advance what procedures are covered, the amount your plan will pay toward treatment and an estimate of 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 its payment based on your current eligibility, amount remaining in your annual maximum and any deductible requirements.
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 that can relate to the type or number of procedures, the number of visits or age limits. These limitations and exclusions are carefully detailed in your plan booklet and warrant your attention.
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 by sending us a request in writing for the specific benefit category or dental procedure range(s).
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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