Confirming how your plan applies

Every dental plan is its own contract. Two people can hold benefits from the same company, through different employers, under contracts that pay quite differently, so the surest way to learn how yours applies is to ask about your specific plan.

You're welcome to call us at (559) 683-4694 with your plan name, the group number, and the subscriber name and date of birth, and ask how your benefits are likely to apply to the treatment you're considering.

The sections below explain how these contracts are structured and why a plan sometimes pays less than expected. It's general information about dental benefits, and your own plan booklet is the document that governs yours.

How a dental plan is structured

A dental plan is a benefit contract, usually purchased by an employer. It makes a fixed amount of money available in a benefit year and sets rules about what that money can be spent on.

Plans typically pay a high percentage toward preventive visits, a lower percentage toward basic treatment such as fillings, and lower again toward major work such as crowns, bridges and dentures. Once the annual maximum is reached, the plan stops paying for that benefit year regardless of what else is found.

That affects how treatment is planned. Benefits generally cover part of the cost of care across a year rather than the whole cost of a large problem, so it helps to know the limits in your own contract while you're making decisions.

The provisions that determine what a plan pays

These are the clauses that decide what a plan pays. All of them appear in your plan booklet, and your employer benefits office can confirm which ones apply to you.

Annual maximum
The most the plan will pay toward your care in a benefit year; costs beyond it are your responsibility. Maximums on many plans have not kept pace with treatment costs. Unused benefit usually does not carry over, so where a large course of treatment can reasonably be divided across two benefit years, you're welcome to ask whether that is an option.
Deductible
An amount you pay before the plan pays anything, usually once per person per benefit year. Some plans waive it for preventive visits, some do not, and some apply a separate family figure.
Benefit categories
Treatment is grouped into tiers, typically preventive, basic and major, and each tier is paid at a different percentage. Which procedure falls into which tier is set by your contract, and it can differ from one plan to the next.
Waiting periods
Many plans will not pay for certain categories until you have been enrolled for a set number of months. Crowns, bridges, dentures and implant work are commonly affected. If you enrolled recently, check this provision before scheduling substantial treatment.
Frequency limitations
A cap on how often the plan will pay for a given procedure. Cleanings, exams, x-rays and sealants commonly carry one. A limitation is a funding rule rather than a clinical recommendation, and some patients need care more often than their contract pays for.
Missing tooth clause
A provision excluding payment toward replacing a tooth that was already missing before the plan started. It commonly affects bridges, partial dentures and implants, sometimes long after the extraction.
Alternate benefit and downgrade provisions
The plan reserves the right to pay toward the least expensive treatment it considers adequate rather than the treatment performed. A tooth colored filling on a back tooth may be paid at the rate for a metal one. You still receive the treatment you agreed to, and the difference in cost is your responsibility.
Exclusions
Procedures the contract does not pay for at all. Cosmetic work is the usual example, along with certain appliances and anything the plan classifies as elective.
Coordination of benefits
Rules for when someone is covered by two plans. The order of billing is set by the contracts themselves, and even two plans together rarely cover the full cost.
Benefit year
The twelve month window the provisions above are measured against. It may or may not follow the calendar year, and it determines when a maximum resets.

How to confirm your benefits

Four steps worth taking before treatment begins, so the figures are in hand while you're still deciding.

  1. Bring the card and the details to your visit

    Bring the plan name, group number, subscriber name and date of birth. Any benefits question starts with those details.

  2. Read your own plan booklet

    It's the document that governs your benefits, and every provision listed above is in it. Your employer benefits office can send you a copy.

  3. Ask what your plan expects to pay

    For anything substantial, a plan can be asked in advance what it expects to pay toward proposed treatment. This is usually called a pre-treatment estimate. The response takes a few weeks and gives you a good picture of what your plan expects to cover. Call us and your plan to ask how to request one.

  4. Decide with complete information

    Weigh what the plan expects to pay, what the treatment costs, and what usually happens if the work is postponed. See payment and financing for how a remaining balance can be handled.

Why a claim can pay less than expected

When the amount paid doesn't match the estimate, one of the provisions above is usually the reason.

  • The annual maximum was already used, often by treatment earlier in the benefit year.
  • A frequency limit had not reset. Cleanings and x-rays are commonly affected, particularly if you were seen at another office earlier in the year.
  • A waiting period was still running on the category the treatment falls into.
  • An alternate benefit provision applied, and the plan paid toward a less expensive option than the one performed.
  • A missing tooth clause excluded the replacement of a tooth lost before the plan started.
  • Eligibility had changed. Employment ended, hours dropped below a threshold, a dependent aged out, or a premium went unpaid.
  • The treatment was an exclusion under that particular contract, and resubmitting the claim does not change an exclusion.

The explanation of benefits your plan sends will show which provision was applied. Some decisions can be appealed, and others reflect the contract working as written. You're welcome to call us at (559) 683-4694 with questions about a statement.

How benefits fit into treatment decisions

A dental plan's schedule of payments comes from an employer contract, so it reflects what was purchased rather than what a particular tooth needs. Where a contract won't fund a treatment, the clinical recommendation stays the same.

What benefits can reasonably affect is timing. We treat urgent problems first, and a larger course of treatment can sometimes be spread across benefit years where that helps. When there are two reasonable options at different costs, we explain both, including the less expensive one.

To see what a given treatment involves, the services pages describe each one in detail. Regular preventive care is usually less expensive than treating problems after they develop.