Overview
Most dental plans include a network of preferred dentists. If you receive treatment from a preferred dentist, you will typically receive enhanced benefits. However, you have the option to receive treatment from the dentist of your choice, even if the dentist is not within the preferred network. Benefits for treatment from non-preferred dentists will be paid at a lower reimbursement level and may be subject to benefit limitations.
Benefits
Below is an example of how a typical PPO dental plan would be structured. The deductibles, coinsurance percentages, and maximums illustrated reflect common benefit plans. However, there are significant variances in the provisions in dental plans provided by different employers. The chart below illustrates typical payment responsibility of participants. For example, 0% means the participant pays 0% of charges or $0.
|
Benefit |
Preferred Dentists |
Non-Preferred Dentists |
|
Deductible Waived for preventive care |
$50 per member; 3 per family |
$50 per member; 3 per family |
|
Maximum Annual Benefit |
Typically $1,500 - $2,000 per covered member |
|
|
Preventive Care Includes routine exams, teeth cleanings, x-rays, etc. Cleanings covered twice per calendar year/12 months |
0% (covered at 100%) |
0% (covered at 100% of UCR*) |
|
Basic Care Includes fillings, endodontics, periodontics, extractions, etc. |
20% (covered at 80%) |
20% (covered at 80% of UCR*) |
|
Major Care Includes crowns, bridges, dentures, onlays, etc. |
20% (covered at 80%) |
20% (covered at 80% of UCR*) |
|
Orthodontia Covers children up to age 19 and adults Separate lifetime maximum of $1,500 per member |
50% (covered at 50%) |
50% (covered at 50% of UCR*) |
Usual, Customary, and Reasonable (UCR*) Defined
Non-preferred benefits are paid based on the member’s geographic location. Your dental carrier will typically pay non-preferred dentists based on a percentage of UCR. For example, the 90th percentile of UCR reflects what nine out of ten dentists charge for a procedure in any given geographic location. If you receive services from a non-preferred dentist, you are responsible for any charges that exceed the recognized UCR amounts.