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Home Comprehensive General Dental Care in Ithaca, NY for the Adult and Child. Including: Preventive, Restorative (Including Cosmetic Restorations), Prosthetic (fixed, removable, and implants), Endodontic (root canals), Tooth Whitening, Occlusal Rehabilitation, Limited Orthodontics and Periodontal Care. |
Dental Insurance for
Individuals Dental plan coverage
for individuals is not commonly offered because dental needs are highly
predictable. For example, you would not pay premiums for your dental
coverage if the premiums were more expensive than the cost of the dental
treatment you need. Since this is the case, insurance companies would
stand to lose money (spend more on benefits than they receive in premiums)
on every individual dental plan they write. There are, however, a
few companies that offer a form of dental benefits for individuals. Most
of these plans are "referral plans" or "buyers' clubs." Under these types
of plans, an individual pays a monthly fee to a third party in return for
access to a list of dentists who have agreed to a reduced fee schedule.
Payment for treatment is made from the patient directly to the dentist.
The third party acts only in the capacity of matching the individual to
the dentist. The dentist receives no payment from the third party other
than in the form of referral of patients. Questions or Concerns About
Dental Benefits Your plan sponsor
(often your employer) should be able to explain the individual design
features of your plan. Design features to understand include: exclusions,
limitations, patient copayments and annual or lifetime benefit
maximums. The American Dental
Association has received numerous questions and complaints from patients
regarding their dental benefits. To correct some of this confusion about
dental coverage, the following questions and answers are provided by the
American Dental Association to help you better understand your dental
benefits. If you have additional concerns or questions, they should be
directed to your group benefits department. Your personal dentist may also
be able to explain dental benefit issues and options for you. My dentist
recommends a treatment that my plan will
not pay for. Does this mean the treatment really isn't
necessary? It is common for dental plans
to exclude treatment that is covered under the company's medical plan.
Some plans, however, go on to exclude or discourage necessary dental
treatment such as sealants, pre-existing conditions, adult orthodontics,
specialist referrals and other dental needs. Some also exclude treatment
by family members. Patients need to be aware of the exclusions and
limitations in their dental plan but should not let those factors
determine their treatment decisions. My dentist recommends that I
get a crown on a tooth, but my dental
benefit will only pay for a large filling for that tooth. Which treatment
should I have? Some plans will only provide
the level of benefit allowed for the least expensive way to treat a dental
need, regardless of the decision made by you and your dentist as to the
best treatment. Sometimes, special circumstances may be explained to the
third-party payer to request an adjustment to this lower benefit
allowance, but there is no guarantee that the third-party payer will alter
its coverage. As in the case of exclusions, patients should base treatment
decisions on their dental needs, not on their dental benefit
plan. My dental plan says that it
will pay 100 percent for two dental checkups and
cleanings each year. However, I just had my first checkup and cleaning,
and now the insurance company says I owe for part of the dentist's charge.
How can this be? Plans that describe benefits
in terms of percentages, for example, 100 percent for preventive care or
80 percent for restorative care, are generally Usual, Customary and
Reasonable (UCR) plans. The administrators of UCR plans set what the plan
considers to be a "customary fee" for each dental procedure. If your
dentist's fee exceeds this customary fee, your benefit will be based on a
percentage of the customary fee instead of your dentist's fee. Exceeding the plan's customary
fee, however, does not mean your dentist has overcharged for the
procedure. These plans pay a set percentage of the dentist's fee or the
plan administrator's "reasonable" or "customary" fee limit, whichever is
less. These limits are the result of a contract between the plan purchaser
and the third-party payer. Although these limits are called "customary,"
they may or may not accurately reflect the fees that area dentists charge.
There is wide fluctuation and lack of government regulation on how a plan
determines the "customary" fee level. Will my plan
cover
the care my family will need? This should be a prime
consideration and a major motivation in choosing one plan over another. If
your employer offers more than one plan, look at the exclusions and
limitations of the coverage as well as the general categories of benefits.
You should discuss your family's current and future dental needs with your
family dentist before making a final decision on your dental
plan. Who is
covered by my dental benefit plan?
What does my dental plan cover? This information should be
provided by the plan purchaser, often your employer or union, and by the
third-party payers. In order that you and the dentist may be aware of the
benefits provided by a dental benefit plan, the extent of any benefits
available under the plan should be clearly defined, limitations or
exclusions described, and the application of deductibles, copayments, and
coinsurance factors explained to you. This should be communicated in
advance of treatment. The plan document should
describe the benefit levels of the plan and list any exclusions or
limitations to that coverage. This document should also specify who is
eligible for coverage under the plan and when that coverage is in
effect. Your dentist cannot answer
specific questions about your dental benefit or predict what your level of
coverage for a particular procedure will be. This is because plans written
by the same third-party payer or offered by the same employer may vary
according to the contracts involved. Therefore, you should ask the plan
purchaser or the third-party payer to answer your specific questions about
coverage. My dentist is not on the list
of dentists provided by my employer. Can I
still go to him or her for treatment? You can always go to the
dentist of your choice. The question is whether you will have benefit
coverage for the treatment you receive if it is provided by a dentist who
is not on the plan's list. This depends on contractual agreements between
the plan purchaser (often your employer), the dentists on the list and the
plan administrator. Under certain contracts, such as a PPO (Preferred
Provider Organization) program, patients are given a financial incentive
to go to certain dentists but do receive some level of dental benefit,
regardless of the treating dentist. Other plans, such as capitation
programs, do not provide any benefit coverage for treatment given by
"non-participating" dentists. In all instances where this type of plan is
offered, patients should have the annual option to choose a plan that
affords unrestricted choice of a dentist, with comparable benefits and
equal premium dollars. My
spouse
and I each have a dental benefit plan. Whose program covers whom? Can we
decide whose program covers our children? Your program covers you. Your
spouse's program covers him or her. You may have additional coverage from
each other's programs if they cover spouses and dependents. In no case
should the benefit derived from the two coordinated programs exceed 100
percent of the dentist's charges for treatment. The primary plan for covering
your children depends on the regulations in your state. Most plans use the
"birthday rule" (spouse with birthday occurring earlier in the calendar
year is primary). Others consider the father's plan primary. The American
Dental Association has recognized the "birthday rule" as the preferred
method for coordinating benefits, but which rule applies to your family
depends on the language in your dental plan documents. If you have two or more
potential sources of coverage, check the coordination of benefits language
for each plan to determine the benefits available. Does my dentist have to send a
description of my treatment plan to the
third-party payer before I have any dental work done? Third-party payers often
request a "predetermination of benefits" on certain treatment plans.
Usually this means a dental consultant will review your dentist's
treatment plan and determine what benefits your plan will provide. But
this predetermination is not a guarantee of payment. You may want to
review your benefit prior to receiving treatment, but the final treatment
decision should be a matter between you and your dentist, regardless of
your benefit. There may be a provision in
your plan that will deny your normal dental benefit, or reduce the level
of coverage if you do not submit the treatment plan for prior
authorization. This is a contractual matter between the plan purchaser
(often your employer) and the plan administrator and is contrary to the
policy of the American Dental Association. The American Dental Association
is opposed to any dental clause that would deny or reduce payment to the
beneficiary, to which he/she is normally entitled, solely on the basis or
lack of preauthorization. Understanding Dental Benefit
Plans Employers and other
plan sponsors offer dental benefits for a variety of reasons, including
promotion of oral health and attraction and retention of high-quality
employees. Regardless of why the
plan is offered, its intent is the same: to help individuals by paying for
a portion of the cost of their dental care. Almost all dental
benefit plans are the result of a contract between the plan sponsor
(usually an employer or a union) and the third party (usually an insurance
company). For this reason, concerns about your dental plan should first be
directed to your plan sponsor. Limitations in
coverage are the result of the financial commitment the plan sponsor has
agreed to make and the benefits the third-party payer will offer in
exchange for that commitment. Treatment decisions
must be made by you and your dentist. While dental benefit coverage should
be taken into account, it should not be the deciding factor in your choice
of treatment. You should know how
your plan is designed, since this can affect significantly the plan's
coverage and your out-of-pocket expense. Some employers now
offer more than one dental plan to their employees. In fact, the right to
choose between two plans could be the law in your state. To understand and
make decisions about your dental benefits, it is important to remember
that plans are often very different. To make the best decision for you and
your family, you should understand exactly how the different kinds of
dental benefit plans work and how they derive their cost
savings. There are many ways
to design a dental benefits plan. Although the individual features of
plans may differ somewhat, the most common designs can be grouped into the
following categories: Direct
Reimbursement programs reimburse patients a
percentage of the dollar amount spent on dental care, regardless of
treatment category. This method typically does not exclude coverage based
on the type of treatment needed and allows the patients to go to the
dentist of their choice. "Usual, Customary and
Reasonable" (UCR) programs usually allow
patients to go to the dentist of their choice. These plans pay a set
percentage of the dentist's fee or the plan administrator's "reasonable"
or "customary" fee limit, whichever is less. These limits are the result
of a contract between the plan purchaser and the third-party payer.
Although these limits are called "customary," they may or may not
accurately reflect the fees that area dentists charge. There is wide
fluctuation and lack of government regulation on how a plan determines the
"customary" fee level. Table or Schedule of
Allowance programs determine a list of
covered services with an assigned dollar amount. That dollar amount
represents just how much the plan will pay for those services that are
covered. Most often, it does not represent the dentist's full charge for
those services. The patient pays the difference. Preferred Provider
Organization (PPO)
programs are
plans under which contracting dentists agree to discount their fees as a
financial incentive for patients to select their practices. If the
patient's dentist of choice does not participate in the plan, the patient
will have a reduction or complete loss of benefits. Capitation programs pay contracted
dentists a fixed amount (usually on a monthly basis) per enrolled family
or patient. In return, the dentists agree to provide specific types of
treatment to the patients at no charge (for some treatments there may be a
patient copayment). The capitation premium that is paid may differ greatly
from the amount the plan provides for the patient's actual dental
care. I would like to
ask my employer to provide a dental benefit plan through the company. How
should I go about doing this? The American Dental
Association recognizes the important role dental benefits have played in
improving access to dental care for millions of Americans. You or your
employer may contact the Association for more detailed information about
how employers of all sizes can provide a cost-effective, high-quality
dental benefit plan for their employees. American Dental Association. |