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Understanding Dental Coverage

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.


Plan Basics

  1. Most insurance companies offer a variety of benefit plans with different features. You may have coworkers 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. You will likely have lower out-of-pocket costs when you visit a network dentist. If you are enrolled in the DeltaCare® USA plan, you must visit your selected primary care dentist in order to receive benefits. Learn more about choosing a Delta Dental dentist.
  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% 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). You are responsible for paying costs above the annual maximum. Consult your plan booklet for specific information about your plan.


Deductibles

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.


Coinsurance

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.


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 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:

  • Class I procedures are diagnostic and preventive and typically are covered at the highest percentage (for example 80 to 100% of the plan's allowance). This is to give patients a financial incentive to seek early or preventive care because such care can prevent a problem or catch it at an early stage.
  • Class II includes basic procedures — such as fillings, extractions and periodontal (gum) treatment — that are sometimes reimbursed at a slightly lower percentage (for example, 70%).
  • Class III is for major services and is usually reimbursed at a lower percentage (for example, 50%). 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, 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.


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 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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