FAQs about Dental Benefits

Why isn’t my dental insurance covering all of my treatment costs?

While the name can be misleading, dental “insurance” should really be referred to as dental benefits. Medical insurance is a payment used to cover the cost of loss. Your dental “insurance” is really a monetary benefit, usually provided by your employer, to help pay for routine dental care. When your employer purchases a dental plan it is based on the amount of benefit and premium costs. The majority of dental plans are only designed to cover a portion of the total treatment cost.

What does this mean for the oral surgeon and me?

Because the dental benefit is small, and oral surgery can be costly, it is rare for a patient’s dental benefit plan to cover the entire cost of the oral surgeon’s care. One surgical procedure on a single tooth can surpass the total maximum benefit. By the time patients see an oral surgeon; they have used some of the benefit on care provided by the general dentist. Therefore, patients are likely to have significant out-of-pocket responsibility for oral surgery that is rendered. Because our office sees most patients on a one-time basis, they do not have the option of collection at future visits.

How does my dental benefits carrier decide the allowed payments?

Often carriers refer to their allowed payments as UCR (usual, customary and reasonable).  However, this can be very misleading and not mean exactly what it stands for. The UCR is a listing of payments for all covered procedures between your employer and the insurance company. This listing reflects the cost of premiums based on your city and state. More than likely your employer has selected a UCR payment that is in relation with the premium cost they desire. More accurately the UCR could be called negotiated payments.

If payments are negotiated, does this mean I will have out-of-pocket costs?
In our experience there is always a portion that will not be covered by your benefit plan.

If there are always out-of-pocket expenses, what good is it to have dental benefits?
While your plan may not cover the entire portion of your treatment, it still covers something. Anything it does help to pay will reduce your portion. It does help to have it!

My dental benefits have an annual maximum. Why?
Your maximum limit is what is required by your carrier to cover each year. Surprisingly, while costs for dental services have steadily been rising, dental annual maximums have not changed much since the 1960s.

Why won’t my insurance pay for some procedures such as x-rays, cleaning and gum treatments?
Your dental benefits contract will specify how many of certain types of procedure they will cover annually. They limit the numbers of items such as x-rays, cleanings and gum treatments they will cover due to the fact many people need to have these done more frequently.

I received an Explanation of Benefits (aka EOBs) from my dental benefits carrier, it states that my bill exceeded the UCR (usual and customary and reasonable). Does this mean you all charged more then you should have?
Good question. Keep in mind what dental benefit carriers call usual and customary is really just the amount negotiated by your employer and the carrier. Usually, it is less than what the oral surgeon in your area might actually charge, and does not mean the oral surgeon is charging too much.


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