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FAQs: Dental

What is an indemnity dental plan, and how does it work?
With an indemnity dental plan, you may use any qualified dentist you wish to receive covered services. Generally, your dentist bills you directly and you file claim forms to be reimbursed. You pay an amount of eligible expenses each year. This is called your deductible. Once you meet your deductible, the plan pays a percentage of your eligible expenses and you pay the balance. The percentage you pay is called your coinsurance.

With an indemnity dental plan, do I name a primary dentist?
The indemnity dental plan does not require you to name a primary care dentist or coordinate your care through a particular dentist. However, you are free to choose a primary dentist.

What are the advantages of an indemnity dental plan?
The main advantage of an indemnity dental plan is that the plan provides the same level of benefits regardless of which qualified provider you see. You do not need to name a particular dentist to coordinate your care, or refer to a network directory when selecting dentists.

Do I need to file claim forms?
Your dentist may handle your expense in one of two ways. Most dentists require you to pay the bill right away. In this case, get a receipt and file it with a claim form to be reimbursed. If the expense is covered, you will be reimbursed for part of the bill. To file a claim, follow the instructions on the claim form. If you have more than one health or dental insurance plan and have received an Explanation of Benefits (EOB) form from another plan, be sure to include a copy with your claim. Sometimes dentists are willing to wait for payment. In this case, you or your dentist will file the receipt and completed claim form with your dental care company. The dental care company will pay the dentist for the part of your expense the plan will cover. The dentist will then bill you for the part the plan did not pay.

What happens in an emergency?
Eligible expenses for emergency dental care are covered the same as other eligible expenses.

What happens if I need care while I’m traveling?
With an indemnity dental plan, coverage is the same for eligible dental services you receive outside your area.

What is a deductible?
Each year, you must pay part of your eligible expenses before the indemnity dental plan begins to pay a percentage of your eligible expenses. This amount is called the deductible.

Are there expenses that don’t count toward my deductible?
Yes. Some of your expenses will not count toward your deductible. For example, amounts your dentist charges above the plan’s allowable amount for a given service will not count toward your deductible.

What is coinsurance?
After you satisfy the deductible, the indemnity dental plan will reimburse you for a percentage of your eligible expenses and you will pay the balance. The percentage you pay is called your coinsurance percentage.

What is predetermination of benefits?
Predetermination of benefits is the process by which a dental care company reviews the proposed treatment and tells you and your dentist how benefits may be paid. It’s a good idea to obtain a predetermination of benefits before expensive services are performed. Have your dentist complete a form showing the proposed treatment and submit it to your dental care company. The dental care company will send your dentist an explanation of what benefits would be covered and what you would have to pay out of your pocket. You can then discuss your treatment options with your dentist.

What’s the amount known as the “allowable amount,” the “U&C amount” or the “R&C amount”?
The terms “allowable amount,” “U&C amount” or “R&C amount” vary by plan but refer to the same thing. The allowable, usual and customary or reasonable and customary amount is the amount usually charged for a given service by most providers in your area. This amount is determined by your dental plan. If your dentist charges you more than this amount, you will not only be responsible for your deductible and coinsurance, but also for the entire difference between the U&C amount and the amount your provider charged. For example, suppose you receive a service for which the “U&C amount” is $100 but your dentist charges you $110. The dental care company will multiply the percentage the plan pays for that service by $100. So even if the service were covered at 100%, you would pay the $10 difference ($110 charge minus $100 U&C).

What are covered services?
Covered services are services covered by the plan. No dental plan covers everything. If you obtain services that are not covered services, you pay the full cost for those services.

DHMO

What is a dental health maintenance organization (DHMO) plan and how does it work?
A dental health maintenance organization (DHMO) plan is a dental care system that provides comprehensive dental services to plan members through a network of dental providers. When you enroll in a DHMO plan, you select a participating primary dentist for each enrolled family member. You may select any participating primary dentist from your plan’s provider directory. Your primary dentist coordinates your dental care, either by providing that care or by issuing a referral to another dentist within the DHMO. With a DHMO plan, you generally pay a fixed amount each time you receive care.

Coinsurance typically does not apply with a DHMO plan. Except in an emergency as defined by the plan, or with previous approval through the plan’s authorization procedures, only services provided by or referred by your primary dentist will be covered under the plan.

What is a primary dentist?
With some DHMOs, you are asked to select a primary dentist to be the personal dentist for each enrolled family member. If you are asked to select a primary dentist, you may select any primary dentist from your DHMO’s provider directory.

What are the advantages of a DHMO plan?
There are several advantages when you belong to a DHMO. Generally: You don’t need to submit claim forms and wait to be reimbursed by your plan. In most cases, you only pay a fixed copayment (fixed dollar amount) at the time you receive covered services. After you pay your copayment, you owe no more payments for the covered services.

How does the DHMO plan work when I obtain care outside the DHMO?
Generally, DHMO plans do not cover services provided outside the DHMO except in certain emergency situations.

My plan requires me to select a primary dentist when I enroll. How do I do so?
When you enroll, you may select any primary dentist from your plan’s network provider directory for each covered family member. Your enrollment materials will request your primary dentist’s name, or a code for that primary dentist from the network provider directory. It’s a good idea to check with your dental care company before you select a primary dentist. Some primary dentists have “full” practices and cannot accept new patients, and others may no longer be participating in the network.

Can I change my primary dentist?
Yes. You or a covered family member may change primary dentists for any reason. Just call the member services number on your ID card.

Do I need to file a claim form with a DHMO plan?
You generally don’t need to file a claim form when you see your primary dentist. Just show your ID card when you receive services so the office knows to charge you a copayment and bill your DHMO plan for the balance. The plan works the same way when your primary dentist refers you to another DHMO doctor or hospital for care. Just show your ID card and pay your copayment. In a true emergency, your eligible expenses may be covered even if you had to go outside the DHMO as long as you follow the DHMO plan’s rules. In this case, the provider will bill you directly. You then need to submit a claim form to be reimbursed. You will be reimbursed for part of the bill. To file a claim, follow the instructions on the claim form. If you have received an Explanation of Benefits (EOB) from another health or dental care company, be sure to include a copy with your claim.

What happens if I need care while I’m traveling?
If it’s not an emergency and you need care while traveling, call your DHMO and your DHMO can help you arrange a referral. In a true emergency, such as an accident that broke your teeth or severe dental pain, get the care you need as quickly as you can. If you are able, contact your DHMO even in an emergency. However, even if you are unable to contact your DHMO, get the care you need. Even if you need to seek care from a non-DHMO provider, your plan may cover emergency care as long as you follow the plan rules.

Do I pay a deductible?
A deductible is the part of your eligible expenses you pay each year before the plan begins to pay benefits. Check your Benefits Summary for details.

Do I pay coinsurance?
Coinsurance is the percentage of eligible expenses you pay after you meet any deductible required by your plan. Check your Benefits Summary for details.

What is a copayment?
A copayment is a fixed amount you pay at the time you receive services.

What is predetermination of benefits?
Predetermination of benefits is the process by which a dental care company reviews the proposed treatment and tells you and your dentist how benefits may be paid. Generally, with a DHMO plan, fees for services are very straightforward, and predetermination of benefits is not necessary to avoid surprises. However, you can always discuss costs and treatment options with your dentist.

What are covered services?
Covered services are services covered by the plan. No dental plan covers everything. If you obtain services that are not covered services, you pay the full cost for those services.

What is an open access dental health maintenance organization (DHMO) plan and how does it work?
An open access dental health maintenance organization (DHMO) plan is a dental care system that provides comprehensive dental services to plan members through a network of dental providers.

When you enroll in an open access DHMO plan, your plan may or may not ask you to select a participating primary dentist from your plan’s provider directory. With an open access DHMO, you may see any provider in the DHMO’s panel without getting a referral. With a DHMO plan, you generally pay a fixed amount each time you receive care. Coinsurance typically does not apply with a DHMO plan. Except in an emergency as defined by the plan, or with previous approval through the plan’s authorization procedures, only services provided by or referred by a DHMO panel provider will be covered under the plan.

Do I need to file a claim form with an open access DHMO plan?
You generally don’t need to file a claim form with an open access DHMO. Just show your ID card when you receive services so the office knows to charge you a copayment and bill your DHMO plan for the balance. In a true emergency, your eligible expenses may be covered even if you had to go outside the DHMO as long as you follow the DHMO’s rules. In this case, the provider will bill you directly. You then need to submit a claim form to be reimbursed. You will be reimbursed for part of the bill. To file a claim, follow the instructions on the claim form. If you received an Explanation of Benefits (EOB) statement from another health or dental care company, be sure to include a copy with your claim form.

Dental PPO

What is a dental preferred provider organization (dental PPO) plan, and how does it work?
A dental preferred provider organization (dental PPO) plan works for you in two ways: through a panel or network of participating dentists, or through dentists you select that are not in the network. Each time you or a covered family member needs dental care, you choose whether to see an in-network or an out-of-network dentist. In-network dentists are listed in your plan’s provider directory. When you use an in-network dentist, also called obtaining dental services in-network, your costs tend to be lower, because the dentists and the network have negotiated to have the dentists accept certain fees for certain services.

With a dental PPO plan, do I name a primary dentist?
The dental PPO plan does not require you to name a primary care dentist or coordinate your care through a particular dentist.

What are the advantages of obtaining my care from in-network dentists?
There are several advantages when you go in-network. Generally: your deductible is lower than when you go out-of-network. You don’t need to submit claim forms and wait to be reimbursed by your plan. With some plans, you pay a smaller percentage of coinsurance when you go in-network. With other plans, you only pay a copayment (fixed dollar amount) at the time you receive covered services. With these plans, after you pay your copayment, you owe no more payments for the covered services.

How does the dental PPO plan work when I go out-of-network?
Generally, you may use any covered dentist you choose. However, your cost will generally be higher and you have certain added responsibilities. For example: Each year, you must pay part of your eligible out-of-network expenses before the plan begins to pay benefits. This amount is called the deductible. After you satisfy the deductible, the plan will reimburse you for a percentage of your eligible expenses and you will pay the balance. The percentage you pay is called your coinsurance percentage, and may be higher than for in-network services. You must complete claim forms and file claims with the dental plan to receive payment of benefits. The plan will not cover any charges above the allowable amount.

When do I need to file a claim form?
You may not need to file a claim form when you see in-network providers. When you do need to file a claim form, as you need to do in most cases when you go out-of-network, your dentist may handle your expense in one of two ways. Most dentists require you to pay the bill right away. In this case, get a receipt and file it with a claim form to be reimbursed. If the expense is covered, you will be reimbursed for part of the bill. To file a claim, follow the instructions on the claim form.

If you have more than one health or dental insurance plan and have received an Explanation of Benefits (EOB) form from another plan, be sure to include a copy with your claim. Sometimes dentists are willing to wait for payment. In this case, you or your dentist will file the receipt and completed claim form with your dental health care company. The dental health care company will pay the dentist for the part of your expense the plan will cover. The dentist will then bill you for the part the plan did not pay.

What happens if I need dental care while I’m traveling?
If you need dental care while traveling, call member services for your dental plan at the number on your ID card. Member services can refer you to an in-network dentist. In a dental emergency such as an accident in which you lose teeth or extreme dental pain, contact member services if you are able and the dental plan can help you decide where to go for care. However, even if you are unable to contact member services, get the care you need. Even if you need to go out-of-network, your plan may cover emergency care at in-network benefit levels as long as you follow the plan rules.

What is a deductible?
A deductible may only apply, or may be higher, when you obtain care out-of-network. A deductible is the part of eligible expenses you must pay before the plan begins to pay a percentage of your eligible expenses.

Are there expenses that don’t count toward my deductible?
Yes. Some of your expenses will not count toward your deductible. For example, amounts your dentist charges above the plan’s allowable amount for a given service will not count toward your deductible.

What is coinsurance?
Coinsurance may only apply to out-of-network care. After you satisfy the deductible, the plan will reimburse you for a percentage of your eligible expenses for out-of-network care and you will pay the balance. The percentage you pay is called your coinsurance percentage.

What is a copayment?
If your plan has copayments, the copayment generally applies to in-network care. With this type of plan, when you obtain care from an in-network provider, you pay only a fixed amount at the time you receive services. That amount is called your copayment.

What is predetermination of benefits?
Predetermination of benefits is the process by which a dental care company reviews the proposed treatment and tells you and your dentist how benefits may be paid. It’s a good idea to obtain a predetermination of benefits before expensive services are performed. Have your dentist complete a form showing the proposed treatment and submit it to your dental care company. The dental care company will send your dentist an explanation of what benefits would be covered and what you would have to pay out of your pocket. You can then discuss your treatment options with your dentist.

What’s the amount known as the “allowable amount,” the “U&C amount” or the “R&C amount”?
The terms “allowable amount,” “U&C amount” or “R&C amount” vary by plan but refer to the same thing. The allowable, usual and customary or reasonable and customary amount is the amount usually charged for a given service by most providers in your area. This amount is determined by your dental care plan. If your dentist charges you more than this amount, you will not only be responsible for your deductible and coinsurance, but also for the entire difference between the U&C amount and the amount your provider charged. This concept only applies for out-of-network care, because PPO dentists have agreed to accept negotiated fees, which are by definition allowable amounts. For example, suppose you receive a service for which the “U&C amount” is $100 but your dentist charges you $110. The dental care company will multiply the percentage the plan pays for that service by $100. So even if the service were covered at 100%, you would pay the $10 difference ($110 charge minus $100 U&C).

What are covered services?
Covered services are services covered by the plan. No dental plan covers everything. If you obtain services that are not covered services, you pay the full cost for those services.