This section provides information that will give you a better understanding of how dental insurance works and how to make it work better for you.
 
Insurance Plan Basics

The insurance plan basics explained here are from what would be considered a high-quality plan, such as those offered by Washington Dental Service. Such a plan is based on prevention and helps patients establish and maintain good oral health.
 
Plan Basics
Benefit Periods
Maximums
Deductibles
Copayments (Coinsurance)
Incentive Plans
Reimbursement Levels
Predetermination of Benefits
Limitations and Exclusions
Glossary of Dental and Benefit Terms
 
 

Plan Basics

The best way to take full advantage of your dental plan is to understand its features. Our best advice is to:

Read your benefit booklet for a complete description of your plan coverage or click on Check Your Coverage for a basic outline of your plan's coverage. To understand unfamiliar terms used in your benefit booklet, go to Glossary of Dental and Benefits Terms.

Washington Dental Service offers a variety of plans with different features. You may have co-workers or friends who are covered by Washington Dental Service, but subscribe to a different plan offered by their company.

Your dentist may not be a participating dentist on the dental plan you have chosen. If your dentist is a participating dentist, he or she will submit your claim. If not, you may be responsible for paying your dentist and submitting your claim to Washington Dental Service or another insurance carrier.

If you are entitled to benefits from more than one dental plan for example, your spouse's plan the amounts paid by the combined plans will not exceed 100 percent of your dental expenses. Benefits for dependents vary from plan to plan. Pay particular attention to special clauses and to language about dependents.

If you are not getting dental benefits through your employer and would like information on individual or independent dental plans, call the Washington state Office of the Insurance Commissioner at (800) 562-6900, or your local chamber of commerce.

Benefit Periods

Most dental benefits are calculated within a "benefit period," which is typically for one year but not always a calendar year. Check Your Coverage or read your benefits booklet to find out when you might be approaching your deductible payments or program maximums.

Maximums

Most dental plans have an annual dollar maximum. This is the maximum dollar amount a dental plan will pay toward the cost of dental care within a specific benefit period. The patient is personally responsible for paying costs above the annual maximum. Again, Check Your Coverage or consult your plan booklet.

Deductibles

Most dental plans have a specific dollar deductible. It works like your car insurance deductible. During a benefit period, you will have to personally pay a portion of your dental bill before your insurance carrier will contribute to your bill. Your plan booklet will describe how your deductible works. Plans do vary on this point. For instance, some dental plans will apply the deductible to preventive treatments, and others will not. To determine your deductible for this benefit period, Check Your Coverage.

Copayments (Coinsurance)

Many insurance plans have a copayment policy. That means the insurance carrier might pay a predetermined percentage of the cost of your treatment, and you are responsible for paying the balance. What you pay is called the copayment. It is paid even after a deductible is reached.

Incentive Plans

Washington Dental Service offers incentive programs for groups. The programs promote prevention by increasing from one benefit period to the next the amount paid for regular visits. For instance, a carrier might pay 70 percent of covered benefits during the first year or during the first benefit period and 80 percent of covered procedures during the second benefit period. This can go up to 100 percent as long as the program is used at least once during each benefit period. However, if a once-yearly incentive program visit is missed, the carrier typically lowers the percentage it pays the next time. Patients who see their dentists once a year can help control their own dental costs.

Reimbursement Levels

Your dental plan probably offers three classes of covered treatment. Each class provides specific types of treatment and typically covers those treatments at a certain percentage. Each class also specifies limitations and exclusions. Reimbursement levels vary from plan to plan, so be sure to Check Your Coverage and/or read your benefit booklet carefully.

Here is the way the three levels typically work:

•  Class I procedures are diagnostic and preventive.   They are typically covered at the highest percentage   (for example, 80 percent to 100 percent of the plan's  approved fee). This is to give patients a financial   incentive to seek preventive care because such care   can prevent most dental diseases.
•  Class II includes basic procedures such as fillings,  extractions and root canal treatment that are  sometimes reimbursed at a slightly lower percentage  (for example, 70 percent to 100 percent). 
• Class III is for major procedures such as crowns,  dentures and fixed partial dentures and is usually  reimbursed at yet a lower percentage (for example, 50  percent). Class III may have a waiting period before  services are covered.

Predetermination of Benefits (Estimate of Benefits)

If your dental care will be extensive, you may ask your dentist to complete and submit a request for an estimate, sometimes called a "predetermination of benefits." This will allow you to know in advance exactly what procedures are covered, the amount the carrier will pay toward treatment and your financial responsibility.

Limitations and Exclusions

Dental plans are designed to help with part of your dental expenses and may not always cover your diagnosed dental or medical need. The typical plan includes limitations and exclusions, meaning the plan doesn't cover every aspect of dental care. This can affect the type of procedures performed or the number of visits. These limitations and exclusions are carefully detailed in your plan booklet and warrant scrutiny. Again, the benefit booklet will help you develop realistic expectations of how your dental plan can work for you.