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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.

Waiting Periods

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.

Age Limits

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.

Out-of-Network Coverage

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.