How Dental Plans Work

Your dental plan is an employee benefit provided by your employer or through an individual plan you selected. The insurance company portion is determined by the contract that you or your employer set with the insurance company. In most cases, the higher the premium paid by you or your employer, the more generous the reimbursement.

As there are thousands of plans in existence, we are unable to know the details of each plan. We do our best to update our records as patients inform us of any benefit exclusions or changes they have with their plan.

We will always diagnose and treat you based on your actual health needs without regard to the limitations imposed by your coverage. To treat you based on only your coverage would not be ethical. Our promise to you is to provide you with the finest care at the most reasonable cost, regardless of insurance coverage.

How Insurance Works

Dental insurance picks up the tab on some covered services and treatments, up to a certain percentage, based on your plan. But make no mistake: you will be responsible for paying some or most of the expenses for most dental care services.

Here are the types of costs with dental insurance plans:

• Premiums: Premiums are what you pay for dental benefits.
• Copays: Copayments are the fixed dollar amount you pay for a service covered under your dental plan, such as a dental exam.
• Deductibles: A deductible is the dollar amount you pay for covered services for the year before insurance benefits kick in. Many dental plans cover preventative procedures with no deductible required.
• Coinsurance: Coinsurance is the portion of the expenses you pay for dental services after your insurance plan has paid its share and you have met your deductible.
• Annual maximums: Your annual coverage maximum is the most your dental insurer will pay for the cost of covered dental care within a benefit plan year. Each time a dental claim is submitted, your insurer deducts the amount they pay for the treatment from your annual coverage maximum. After reaching this maximum, you are responsible for 100% of the expense of additional dental treatments within that plan year. Once your next plan year starts, your annual coverage maximum resets.

What Is the Difference Between In-Network and Out-of-Network?

Being out of network simply means that Encompass Dental Studios does not have a direct contract with your insurance provider. It does not mean we will not take your insurance. We take all insurances unless they are a DHMO, which is the dental version of an HMO and only allows for benefits to their members if they go to a dictated office within their network. For those carriers that we do have a direct contract with, they have negotiated prices. When out of network, we use the base price for the service and apply the coverage percentages that correspond to your out-of-network benefits to calculate what you will owe.

For Services Not Covered by Your Dental Plan

We believe in the importance of quality dental care, and we strive to provide the best treatment possible while focusing on affordability. We encourage dental service options that ultimately prevent more costly treatments in the future. We at Encompass Dental Studios will do our very best to help you maximize your insurance benefits. With that being said, Dr. Alexander will not lower the standard of care nor recommend an inferior treatment option to fit potential limitations of a benefit plan. Our responsibility is to you, our patient, and making sure you receive the best care you deserve and need to be healthy.

Occasionally, patients in our office request procedures that are not covered by their dental plan. We are happy to provide these services but want you to understand the financial implications. Many insurance companies are either unaware of or ignore the state law stated on the explanation of benefits (EOB) sheet that the patient does not owe any more for the service provided, when in fact they do own more.

For example, a patient may request a porcelain dental crown or filling, but their dental plan only covers a metal one. The insurance company will calculate the benefit to you on the EOB based upon a similar procedure covered by the plan, often referred as an “alternate benefit.” However, you have now received a procedure that was not covered by your dental plan. Therefore, we are allowed to bill you the difference between the benefit calculated on the EOB and our office fee for that procedure.
In 2012, the legislature passed LB 810 to address a situation occurring with insurance dental plans, specifically an insurance company attempting to limit the fee a dental office could charge a patient, even though the dental plan did not provide a benefit for a particular procedure sought by the patient. LB 810 modified §44-7,105, which is below:

§ 44-7,105. (Effective 7/19/2012)

Notwithstanding section 44-3,131, (1) an individual or group sickness or accident policy, certificate, or subscriber contract delivered, issued for delivery, or renewed in this state and a hospital, medical, or surgical expense-incurred policy, (2) a self-funded employee benefit plan to the extent not preempted by federal law, and (3) a certificate, agreement, or contract to provide limited health services issued by a prepaid limited health service organization as defined in section 44-4702 shall not include a provision, stipulation, or agreement establishing or limiting any fees charged for dental services that are not covered by the policy, certificate, contract, agreement, or plan.

When it is decided by you and Dr. Alexander on what procedure(s) will best address your dental and oral health needs, it may be revealed that your dental insurance does not cover that particular procedure as a benefit of your particular plan. However, if you choose to receive a higher-level procedure that is not covered, we will need to bill you for the difference between your plan benefit and our office fee.
We appreciate your understanding and acknowledgement of this situation.

Common Examples of Limitations in Dental Benefit Plans

• Frequency Limitations — Limitation: Dental cleaning is a benefit only twice per benefit period. A third cleaning would not be covered by your plan.
• Topical Fluoride Applications — Limitation: Topical fluoride is a benefit eligible once every 12 consecutive months for children under age 15. Therefore, a child age 15 or under who receives a second topical fluoride within 12 months is not covered.
• Periodontal Maintenance Therapy — Limitation: Periodontal maintenance services are available twice per year. A third periodontal maintenance service in the same year would not be covered.
• Alternate Benefit Services — A filling, for example, can be an amalgam (silver) filling or a composite-tooth-colored filing. Each has a separate dental code and price with the tooth-colored filling generally being more expensive. Most dental benefit plans do not cover a tooth-colored filling, and many patients do not want an amalgam filling. The same example applies for a steel crown (covered) and tooth-colored crown (not covered). Some dental benefit plans refer to this as the least costly treatment rule.
• Annual Benefit Cap — Most dental benefit plans have an annual cap or allowance (usually between $1,000 and $1,500 per year). If any dental service is provided and you have exceeded your annual benefit cap, the service is not covered.
• Waiting Periods — Some plans require a waiting period before a patient’s benefits begin to take effect. If you as the patient have not waited long enough for the benefits to begin, the service is not covered.

The above examples are only a partial list of limitations and exclusions that appear in dental benefit plans that apply to coverage.

If Dental Benefit Plan never pays for ______________, then ________________ is not “covered by the policy” and Dental Benefit Plan cannot dictate the price for that service.

Nebraska Department of Insurance letter, April 8, 2015.

Be sure to check your dental benefit plan for a complete list of limitations and exclusions.