Dental insurance is a benefit to help with costs incurred at the dental office, but sometimes it doesn’t always pay what we think it should. Insurance plans are chosen by either your employer or by yourself (if you choose to have an individual plan). Some insurance plans have a specific list of dentists (in-network providers) where you will receive full benefit of your plan. However, these plans may also allow you to go to any dentist (out-of-network) but may not pay the full benefit of your plan.
A common question from patients is “why didn’t my insurance pay better, they should have covered that at 100%?” Those types of plans work on a Usual, Customary and Reasonable rate (UCR). This rate is a set amount that is determined by the insurance companies for what they will pay for procedures. Unfortunately, this rate is not disclosed to providers or patients, is not the same for all insurance companies and isn’t necessarily determined by the cost of living in your particular geographic area.
For example, an insurance company that works off of a UCR may determine that they will pay 100% on preventive care (cleaning and exam) but have a maximum amount for those procedures to be $100. So if you go to a dentist (out-of-network) that charges $150 for cleaning and exam you will be responsible for the remaining $50 since the UCR is $100. Dental insurance is a great benefit. It typically doesn’t cover all expenses but helps to reduce the cost. Overall, it is the responsibility of the insured (subscriber) to understand what type of plan they have and understand what type of coverage they will receive from the dental office they choose.