This can be complicated and confusing so please read on. How is my dental plan different from other plans? 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," out of your income 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. The 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 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 usually do 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, let's 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. If you are not satisfied with your dental benefit plan, talk to your employer. The American Dental Association supports an insurance plan entitled Direct Reimbursement or fee-for-service freedom of choice dental plan. Direct Reimbursement plans take many forms, but all DR plans share three essential elements: l) they are self-funded by the employer; 2) they allow freedom to choose any dentist; and 3) they reimburse patients based on dollars spent on dental treatment, not based on type of treatment received. With a DR plan in place, the covered individual visits the dentist, receives treatment and arranges for payment, and later presents a paid receipt or proof of treatment to the employer for reimbursement. The employer then reimburses the employee directly, based on the company's plan design. The plan design will vary according to a company's budget. Some companies administer the plan themselves and others use a third-party administrator (TPA) to profess and reimburse claims. For additional information call the ADA at 800-621-8099 ext. 2746.