Related Sponsors

Does Dental Insurance Have Limitations?

Home » Insurance » Dental Insurance » Does Dental Insurance Have Limitations?

Dental insurance is designed to help you get the care you need at a reasonable cost. Because each person's oral health is different, costs can vary widely. To control dental treatment costs, most plans will limit the amount of care you can receive in a given year. This is done by placing a dollar cap or limit on the amount of benefits you can receive, or by restricting the number or type of services that are covered. Some plans may totally exclude certain services or treatment to lower costs.

There are certain limitations and exclusions in most dental benefits plans that are designed to keep dentistry's costs from going up without penalizing the patient. All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes dental coverage and health insurance may overlap. Exclusions in your dental plan may be covered by your medical insurance.

By choosing plans that impose dollar or service limitations, rather than those that exclude categories of service, you can receive the care that's best for you and actively participate with the dentist in the development of treatment plans that give the most and highest quality care.

Some plans encourage you or your dentist to submit a treatment proposal to the plan administrator before receiving treatment. After review, the plan administrator may determine: the patient's eligibility; the eligibility period; services covered; the patient's required co-payment; and the maximum limitation. Some plans require predetermination for treatment exceeding a specified dollar amount. This process is also known as preauthorization, precertification, pretreatment review or prior authorization.

To help contain costs, your plan may limit your benefits by number of procedures or dollar amount in a given year. In most cases, particularly if you've been getting regular preventive care, these limitations allow for adequate coverage. By knowing in advance what and how much your plan allows, you and your dentist can plan treatment that will minimize your out-of-pocket expenses while maximizing compensation offered by your benefits plan.

Many plans provide a peer review mechanism through which disputes between third parties, patients and dentists can be resolved, eliminating many costly court cases. Peer review is established to ensure fairness, individual case consideration and a thorough examination of records, treatment procedures and results. Most disputes can be resolved satisfactorily for all parties.

Next Page: Will I Benefit From Dental Insurance?

Related Dental Insurance Articles