Dental benefits vary widely between carriers, but there are certain restrictions and limitations that are fairly common. These include preexisting conditions, annual maximums, and managed care cost containment measures.
Some group health plans restrict coverage for dental conditions that are present before an individual enrolls in the plan, such as missing teeth. These restrictions are known as “preexisting condition” exclusions. If a plan imposes pre-existing condition exclusions, the length of the exclusion must be reduced by the amount of any prior creditable coverage. Most coverage can be considered creditable coverage, including group dental coverage, COBRA continuation coverage, or coverage under an individual dental policy.
Dental plans may use the terms “Usual, Customary, and Reasonable” (UCR) to determine the portion of the dental treatment fee they are willing to pay for a particular procedure. However, the words usual, customary and reasonable are not interchangeable and UCR is a misleading acronym.
UCR is actually three different concepts, not one. Usual fees are determined by the dentist. The fee the insurance company determines to be customary may be lower than the area dentists’ usual or reasonable fees for the same service. There is no universally accepted method for determining the customary fee schedule, which may vary a great deal among plans, even when those plans operate in the same area. So, the benefit paid will generally be based on a percentage of the insurance company’s customary fee schedule. Patients often do not know what their out-of-pocket costs will be because third-party payers generally do not release these customary fee schedule maximums to the public.
Many dental plans feature a total annual maximum – a maximum dollar amount that may be reimbursed each year, even if the patient’s dental costs exceed that limit. These totals can be based on individual or family maximums.
Cost containment measures are features of a dental benefit program, or of the administration of the program, designed to reduce or eliminate certain charges to the plan. Dental plans should disclose information on how cost containment measures are used, or how they will affect the claim being considered.
Managed care dental plans are health plans that integrate the financing and delivery of health care services to covered individuals by means of some or all of the following:
• Arrangements with selected providers to furnish services to members
• Defined criteria for the selection of dental care providers
• Significant financial incentives for members to use contracted providers
• Procedures associated with the plan, subject to limitations and exclusions
• Formal programs for quality assurance and utilization review
For a more detailed explanation about managed care cost containment measures, such as least expensive alternative treatment clauses, bundling of dental procedures, downcoding, predetermination, deductibles, and coinsurance provisions, refer to section F in Dental Benefits: An Introduction.