Dental Benefits Explained

You and your dentist are partners in taking care of your dental health. It’s important to understand your dental plan, what your responsibilities are and where your dentist comes in.

Dental Plan Basics

Some patients will buy their own dental plan, but most have dental benefits provided by their employer. When your employer chooses your insurance plan, they consider things like the plan’s cost and how often employees use their benefits.

Although they choose the plan, your employer is not responsible for administering your dental plan. Instead, they enter into a contract with an insurance company who then acts as your dental plan administrator. Your dental plan administrator must reimburse you based on the terms of the dental plan contract.

For some dental services, payment is based on a cost-sharing arrangement between you and your employer. In these cases, you pay for part of the cost, while the plan pays for the rest.

Dental Plans Versus Treatment Plans

Here’s a helpful tip: a dental plan and a treatment plan are two different things.

• A dental plan is usually part of a health benefits package you get through your workplace. It can also be purchased on its own. Dental plans define which treatments are eligible for reimbursement.
• A treatment plan is a personalized approach you and your dentist develop to treat your dental health needs. It serves as your roadmap to good oral health and should not be limited by what your dental plan covers.

Keep in mind that all benefit plans have limitations. Even though treatment may be necessary, it is not always covered in your dental plan. 

Your Responsibilities

Your dentist may not be familiar with your specific plan coverage so it’s important to know how your plan works. Always read the information booklet or other materials available from your benefits provider.

Some things you should 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?
• How much am I covered for cleanings and X-rays?
• How much am I covered for fillings and root canals?
• What about other treatments like bridges and crowns, dentures and oral surgery?

You should also be aware of your co-payment. Co-payment — also called co-insurance — is the part of the bill you won’t be reimbursed for. Many dental plans have a percentage of the claim amount (typically 20 to 50 per cent) that is not covered by the dental plan.

Can my dentist waive my co-payment?

No — waiving a co-payment is insurance fraud and is against the law. Your dentist could be fined or even lose their license. 

The claim forms you and your dentist sign state which services were provided and how much was charged. The insurance company pays its share based upon the assumption that you will do the same. 

Your Dentist’s Responsibilities

Dentists make their treatment plan based on your dental needs. Sometimes, your dental plan coverage and your treatment plan won’t align. If your dental plan only covers part of the cost of your treatment plan, you’ll need to cover the rest.

Your dentist will take you through your personalized treatment plan and answer any questions you may have. They can also help you understand how much may be covered before you move ahead by submitting a pre-treatment form to your dental benefits administrator. Your benefits administrator will provide you with a “predetermination of benefits”. This doesn’t guarantee that the treatment will be covered by your health insurance plan. But it will show you what services are covered and the limitations of your plan.

Remember that your dentist is treating you, not your dental plan. Read more about your dentist’s obligations according to the Royal College of Dental Surgeons of Ontario.