What is Usual, Customary and Reasonable?

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Almost all dental insurance companies use what is called a “usual, customary and reasonable” (UCR) fee guide. This means that they set their own price that they will allow for every dental procedure that they cover. This is not based on what a dentist actually charges, but what the dental insurance company wishes to cover. For example, your dentist may charge $78 for a dental cleaning, but your insurance company will only allow $58 because that is the UCR fee that they have set.

If you are on a dental insurance policy that requires you to go to a participating provider, you should not be charged the difference between these two prices. A contracted dentist generally has an agreement with the dental insurance company to write off the difference in charges. If the policy allows you to go to a dentist of your choice, check the insurance company’s UCR fee guide against the fees that dentist charges. You may be required to pay the difference out of your pocket, however, you cannot put a price tag on quality dental care.

What is Direct Reimbursement

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A direct reimbursement plan is a dental insurance plan that is usually entirely funded by your employer and allows you to choose any dentist without the hassle of networks.

With a direct reimbursement plan, you are reimbursed for money spent on dental work, which is not limited to specific treatments. Some employers may choose to reimburse you after you have paid for your dental work, and some may choose to pay the dentist directly — leaving you with less out-of-pocket expense.

What is Yearly Maximum?

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The yearly maximum is the most money a dental insurance plan will pay out within one full year. A yearly maximum could run on a calendar year (January to December), or on a fiscal year, depending on the dental insurance company.

The yearly maximum will automatically renew every year. If you have unused benefits, these will not roll over. Most dental insurance companies allow an average yearly maximum of $1,000.

What are Dental Insurance Coverage Types?

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According to most dental insurance companies, dental procedures are broken down into three categories:

  1. Preventative
    Most insurance companies consider routine cleanings and examinations as preventative dental care, however, X-rays, sealants and fluoride can be deemed as preventative or basic, depending upon the specific insurance carrier.
  2. Basic or Restorative
    Basic or restorative dental treatment usually consists of fillings and simple extractions. Root canals can be considered basic or major. However, the majority of dental plans list root canals as basic.
  3. Major
    Crowns, bridges, dentures, partials, surgical extractions and dental implants are dental procedures that most dental insurance companies consider as a major procedure.

Since all dental insurance carriers are different, it is important to clarify which dental procedures fall under each specific category. This is important because some insurance plans don’t cover major procedures and others have waiting periods for certain procedures. If you know that you will need major dental work that is not covered by a given plan, you should probably look elsewhere to find one that suits all of your needs.