Understanding Your Dental Insurance / Maximizing Dental Benefits
1. How does your office file insurance claims? How long will it take to get reimbursed?
We file claims electronically. Usually, patients are reimbursed within two or three days. Quick receipt of your reimbursement cheque minimizes the time you are out of pocket.
2. What are my responsibilities in regards to my dental plan?
It is your responsibility to be familiar with the terms of your dental plan, and you are responsible to pay any fees to your dentist and collect payment from your insurance company. To avoid misunderstandings, we recommend that patients feel free to discuss any concerns with us.
Here is a checklist of questions you should ask in order to become sufficiently educated about your dental plan:
3. How do I get the most from my dental benefits?
First, read your benefits booklet. Be familiar with your options—know the limitations and exclusions set by the policy. However, always remember that you and your dentist should decide what treatment is best for you, no matter what insurance may or may not cover.
Stay in contact with your dentist, employer, and insurance company. Let your benefits office know how your plan is or isn’t working.
Maintain good dental hygiene! Good dental health is your responsibility, and preventative measures are the least expensive—and prevent much pain down the road.
Lastly, take advantage of your benefits since you are paying the premiums.
4. Why does my insurance pay less than I was told?
There are several reasons that your reimbursement may be less than you expected. First, you insurance company may base their payouts on a specific provincial year and fee guide. Second, it’s common for an insurance policy to reimburse you only for the cost of the least expensive treatment. Conflicts can arise when this least-expensive treatment is not the treatment you or your dentist has selected as the best treatment for you. Lastly, some treatments are covered at a lower percentage; for example, crowns may be covered at 50 percent and fillings at 70 percent.
Your family or group may be using more services than planned, or inflation may be pushing up the cost of all goods and services. The bottom line is that insurance companies raise prices for the sake of continued profits.
6. How should I handle problems with my dental benefits?
First, check your benefit booklet. Then go to your plan’s administrator (in most cases, your company's benefits office) or your union representative.
7. Do I really have to pay my co-payments?
Yes! Despite the belief of some patients, dentists cannot legally waive co-payments. Under 1991’s Dentistry Act, dentists must make a reasonable attempt to collect the portion of dental fees for which the patient is responsible (i.e. the co-payment). In addition, dentists are professionally obligated to collect co-payments.
8. Where can I learn more about dental insurance?
Two good resources are the Ontario Dental Association’s explanation of dental benefits and insurance and the Canadian Dental Association’s explanation of dental plans.
Common Insurance Terms:
CO-PAYMENT: The part of the fee you owe (i.e. the amount not covered by your dental plan). Typically, co-payments are 20 to 50 percent of the claim amount. In all cases, patients are responsible for their co-payments; dentists are bound by the law and their code of ethics to collect co-payments.
EXCLUSIONS: Typically, dental plans do not cover all procedures. Certain cosmetic procedures, orthodontics, dental implants, and other newer treatments are typically excluded from insurance coverage.
LEAST EXPENSIVE ALTERNATE TREATMENT: Sometimes, a person’s employer will buy a plan that allows the insurance company to pay for a less costly treatment that the insurance company has deemed “adequate.” For example, an insurance company may cover a partial denture instead of fixed bridgework, which is more expensive. However, always keep in mind that you and your dentist must decide the best treatment for you.
LIMITATIONS: Insurance companies put limitations on how often you can undergo a certain procedure. In many cases, these procedures are not covered as often as you need. Limitations vary according to the plan. For example, the insurance company may cover cleanings twice a year when a patient requires cleanings four times a year.
PREDETERMINATION: Some contracts require you to send in treatment plans before you begin treatment. The insurance company then determines which benefits they will pay for. Be warned that if you treatment plan changes, you may have to notify your insurance company.
REASONABLE: Insurance companies sometimes adjust fees according to the circumstances of treatment. For example, dental fees may be adjusted in the case of a patient with advanced heart problems, or a child with behavior problems. It is to your benefit to check that your dentist is noting any of these complications when they submit your claims!
TABLE OF ALLOWANCES (SCHEDULE OF BENEFITS): This denotes that your employer has chosen a contract that sets specific monetary limits for each procedure. These caps may not cover the total cost of treatment, and the patient is responsible for the difference.