Are you new to dental insurance? Feeling confused about the details of
your policy or how your coverage will work? We understand that dental
insurance can make a person feel clueless, which is why we explain a few
things about group
dental insurance that will hopefully answer your questions.
A common term you will come across in your dental plan is “waiting
period.” This term can cause confusion and skepticism, but essentially,
a waiting period is a set length of time in which a member needs to be
enrolled before they can use certain aspects of their dental plan. If
you have a 3 month waiting period for basic services, you won’t
be able to take advantage of these services until 3 months after the effective
date for your policy. Waiting periods often don’t apply or are waived
if you enroll in a new plan after you have already been covered for a year.
Some dental plans have services that are only available to people under
a specific age. However, most dental services included in a plan do not
have age limits. Orthodontics and fluoride treatment are two services
where age limits typically apply. Orthodontic services tend to have an
age limit of 19, while fluoride treatment and sealants are generally covered
until age 14.
You might be wondering what would happen if you were to visit a dentist
who is “out-of-network,” particularly if your visit will be
covered. Before we get into that, you need to first know the difference
between a PPO dentist and a non-participating dentist:
- PPO dentists belong to one of the insurer’s networks of dental providers
- Non-participating dentists don’t belong to any of the insurer’s networks
If the dentist is in-network, your insurance company will cover the percentage
of the cost listed in your plan. For out-of-network dentists, it’s
a little more complicated.
First, you need to know if you have a MAC plan or a UCR plan. MAC stands
for Maximum Allowable Charge, while UCR stands for Usual, Customary, and
Reasonable. These two terms will determine your coverage when you go to
an out-of-network dentist.
With a MAC plan, reimbursement for services at an out-of-network dentist
are capped at the Maximum Allowable Charge. So if your out-of-network
dentist charges $150 for services, but your MAC is $100, you will be responsible
for paying the $50 difference.
UCR plans limit your reimbursement is based on the Usual, Customary, and
Reasonable value for your geographic area. The UCR value is calculated
for each dental procedure by tracking all the claims submitted for a particular
procedure within a specific geographic area. So with a UCR, a certain
percentage of fees are charged for your out-of-network services.
Do you have more questions about your group dental plan? Call (888) 451-0883
to speak with our Atlanta Insurance Administrators
today. Our team of professionals can answer your questions or help you
find a dental insurance policy that is right for you.