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The facts to help you understand your dental insurance options:

- No insurance plan covers all dental expenses. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is the patient's responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by their insurance company.

- Insurance companies are in business to make money. They make more by paying fewer benefits. They also profit more by waiting to pay claims and by making dentists send in pre-estimates on the more expensive procedures. Delays in treatment results in less treatment.

Why doesn't my insurance pay for this?
UCR (Usual, customary and reasonable):
Under a UCR plan, patients are usually allowed to see the dentist of their choice. These plans pay an established percentage of the dentist's fee or pay the plan sponsor's "customary" or reasonable" fee limit, whichever is less. Although these limits are called "customary," they may or may not reflect the fees that area dentists charge.

It may also be noted on your bill the fee that your dentist has charged you is higher than the reimbursement levels of UCR. This does not mean your dentist is overcharging you. For example, the insurance company may not have taken into account up-to-date, regional data in determining a reimbursement level.

WHY? There is no regulation as to how insurance companies determine reimbursement levels, resulting in wide fluctuation. In addition, insurance companies are not required to disclose how they determine these levels. The language used in this process may be inconsistent among carriers and difficult to understand.

Your plan purchaser makes the final decisions on "maximum levels" of reimbursement through the contract with the insurance company.
Even though the cost of dental care has significantly increased over the years, the maximum levels of insurance reimbursements have remained the same since the late 1960's. Many plans offer higher maximums that are comparable to rising dental care costs.

Your plan may want you to choose your dental care from a list of their preferred providers. Whether or not you choose your dental care from this defined group can affect your levels of reimbursement.

Your dental plan may only allow benefits for the least expensive treatment for a condition. For example, your dentist may recommend a crown, but your insurance may only offer reimbursement for a large fillings. As with other choices in life -- such as purchasing medical or automobile insurance, or buying a home--the least expensive alternative is not always the best option.

Just like your medical insurance, your dental plan may not cover conditions that existed before you enrolled in the plan. Even though your plan may not cover certain conditions, treatment may still be necessary.

Your dental plan may not cover certain procedures, or preventative treatments such as sealants that can save you money later. This does not mean these treatments are unnecessary. Your dentist can help you decide what type of treatment is best for you.

This table will help you understand dental insurance:


Traditional Indemnity Dental Insurance

Professional Provider Organization (PPO)

Health Maintenance Organization (HMO)

This plans were the original dental benefit plans that have provided good dental coverage for decades. This is the best of all 3 plans

These organizations provide dentistry through contracted dentists who agree to accept lower fees.

Minimum dentistry is provided through contracted dentists who agree to small monthly capitation payments for each employee/patient regardless if services are performed or not.

Patient's Freedom of Choice

Patients choose their own dentist. (most freedom of choice)

Patients have more freedom of choice than with an HMO, but pay more for care from a non-preferred provider.

Patients are restricted to a list of designated providers. (least freedom of choice)


The levels and coverage are defined by a contract, and generally provide more comprehensive services than PPO's & HMO's.

Enrolled members receive services at a reduced cost when the services are delivered by a preferred provider.

Enrolled members receive minimum comprehensive services when care is provided by a plan provider.


Many or may not be controlled by the carrier.

Less controlled than an HMO.

Providers receive a financial incentive to control utilization.

Payment to the Providing Dentist

Dentists are paid (indemnified) for services by the insurance company and the patients.

Dentists are paid on the basis of a discounted fee schedule.

Dentists are paid a small dollar amount per member per month regardless of services rendered.

A better alternative to traditional dental insurance benefit plans:

- Direct reimbursement is a simple, cost-effective way for a company to provide dental benefits to their employees without using a third party insurance company.

- Direct reimbursement plans are structured similar to traditional insurance plans in regards to deductibles, co-payments and maximum annual benefits.

- It differs because it saves the employer in benefit costs, and it allows the employee to select the dentist of their choice.

The Advantages to the Patient?
- Patients have the freedom of choice that allows them to select their own dentist.
-Patients have the freedom to select the dentistry of their choice following their dentists' recommendations. An insurance company does not dictate your treatment.
- Before treatment, patients will know exactly what their portion of the fees will be.
- Patients can receive quality dentistry according to recommended ADS treatment guidelines instead of an insurance company's restrictive guidelines.
-There are no delays in treatment while waiting for pre-estimate approvals from an insurance company.

Advantages to the employer?
- Employers can save 20 - 30% on their dental benefits program by setting up a self-funded direct reimbursement plan that eliminates the middle-man, the insurance company.
- No third party is involved. DR is a simple arrangement of dental benefits between employers and their employees.
- Virtually all monies allocated go directly towards dental services.
- Employers have much more control and flexibility in designing their own benefits plan to meet their needs.
- Direct reimbursement plans can be arranged for small companies with only a few employees or large companies with thousands.
- Employers are greatly appreciated by their employees when providing the best possible benefits