Dental Plan

How Dental Plans works?


Many employers provide benefits, in addition to salaries, as a method of paying their employees. In fact, the benefits portion usually ranges from approximately 20 to 34 percent of the employee’s total compensation package.

Independent research conducted by the Ontario Dental Association indicates that, of the benefits provided to Canadian employees, dental coverage consistently ranks as one of the most important and most desirable aspects of employee benefit plans.

First, remember that a dental plan and a treatment plan are two different things:

•    A dental plan is a means to help you to pay for your dental treatment. Employers provide health and dental benefits for a variety of reasons, including the promotion of good health.

•    A treatment plan is the personal plan you and your dentist develop together to meet your oral health needs. It serves as your road map to good oral health and should not be limited by what a dental plan will cover.

In order to be able to offer a dental plan, many employers are developing creative alternatives in the design of benefit plans so that the employee will share in the cost of the dental care. 
What plan limitations are employers using to involve the employee in dental care costs?

Some of the most common benefit plan designs currently being offered are:
(1)Annual Deductible Amounts 
In this case, the employee may be required to pay the first $25 or $50 claimed every year.

(2) Frequency limitations
Dental plans may limit the number of visits to the dentist each year that will be covered by the insurance plan.

(3) Annual Dollar Maximums
Employers may create a maximum limit (e.g., $1,500) that the dental plan will cover each year.

(4) Co-Payment (or co-insurance)
Through a sharing formula specified in the dental plan contract, the dental plan may only cover a percentage of the eligible amount claimed. The employee is responsible for paying the remainder.

Co-payments are sometimes applied to diagnostic, preventative and basic services, but they are more frequently applied to comprehensive or extensive services such as endodontics (i.e. root canals), periodontics (i.e. dental implants), prosthodontics (i.e. dental bridge) and orthodontics (i.e. braces).

Sometimes your plan will cover 80 percent of the bill leaving you to pay the other 20 percent (an 80 – 20 Co-pay), other times, it could be on a 50 – 50 basis, or even other amounts. It all depends on the plan. Here’s how co-payment works: Your dentist bills you for $100 for your dental treatment. Before the claim form goes to your insurance company, your authorization is required, verifying that the charge is accurate and that you are financially responsible to the dentist for the entire charge. This is an important step because your dental plan may not cover the whole bill. For example, if your plan pays 80 percent of an eligible expense of $100, your insurance company will cover the first $80 leaving you responsible for paying the remaining $20 as an out-of-pocket expense. Insurance companies reserve the right to request that the patient provide proof that the co-payment has actually been paid. If the patient is unable to provide that proof, the insurance company may demand that the patient make financial restitution to the insurance company or it may apply the overpayment to future claims payments. 

Your dentist may give you a discount but this is very different from waiving a co-payment. If your dentist discounts his/her fee to you by a certain percentage, then that discounted fee must be the fee submitted to your insurance company as the whole fee charged for the services rendered. Your dental plan is a valuable benefit. Before you ask your dentist to waive a co-payment, think about the consequences to you and your dentist.

 The waiving of a co-payment is insurance fraud and is against the law. Your dentist could be heavily fined or even lose their license. 

f you have a dental plan:

It's up to you as a full partner in your oral health care to know how your plan works. Read the booklet or other materials available from your provider.
Some things you need to know about your plan:
•    What is covered each year?
•    Is there a deductible?
•    Is there a total dollar limit on my coverage?
•    Can I choose a procedure other than the one my plan covers?
•    Will I still be covered if I change jobs?
•    To what extent am I covered for cleanings and x-rays?
•    To what extent am I covered for dental treatments such as fillings and root canals?
•    What about other treatments such as bridges and crowns, dentures and oral surgery?

Your dentist can assist in claiming your benefit and help you estimate how much will be covered before you move ahead. They can submit a pre-treatment plan to your dental plan administrator for a pre-determination of benefits. This is not a guarantee, but it does reduce the chances of your claim for reimbursement being limited or declined.
As mentioned earlier, your dental plan should never dictate your treatment plan.
Remember that your dentist is treating you, not your dental plan.
Information courtesy of Ontario Dental Association and Canadian Dental Association


Dr. Parisa Eghbalian

Born and raised in Iran, Dr. Parisa Eghbalian, graduated from Tabriz University of Medical Science in 2001. Prior to immigrating to Canada in 2010, Dr. Parisa worked as an associate for nine years.

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