It is important to understand that the dental clinic does not know the details of your dental plan coverage; this information is protected by the Personal Information Protection Act. However, the dental clinic can work with you to determine what services may be covered. A dental plan can help you cover some of the costs of child's dental care. However, it is important to understand that your dental plan may not cover all of the treatment needs.
- Dental plans are not customized to your child's individual dental health needs and may, or may not, cover all the treatment needs.
- Know what your plan covers including services, percentage coverage and/or treatment limits. Ask your plan purchaser/plan provider for details.
- You must pay the co-payment, the portion not covered by the plan.
Your dentist's responsibility is to your child's health. He or she will:
- Provide treatment recommendations based on your child's dental health care needs; this may, or may not, be covered by your plan.
- Submit a pre-determination to your plan provider, if appropriate. This will provide an estimate of what your dental plan will cover prior to treatment.
Confirm plan coverage: Before you visit the dental clinic always ensure you share any relevant information with the dental clinic, such as changes to your plan, any recent claims and/or past treatment that may affect your coverage.
Ask for a pre-determination: Once you review, discuss and agree on a treatment plan with the dentist, the dental clinic can submit a pre-determination to your plan provider. A pre-determination provides you with an estimate of what costs your dental plan will cover and what you will be responsible for. Please be aware this is not a guarantee of coverage.
Important Note: A pre-determination is usually valid for a fixed period of time (i.e. six months to a year) however, it is based on available coverage at the time the predetermination is submitted and approved. Therefore, it is important to be aware that if, between the time a predetermination is obtained and the time you receive treatment there are any changes and/or any limits reached on your plan, the final amount of the treatment your plan covers may change. If you have any doubts, reconfirm coverage with your plan provider before your treatment takes place.
Discuss payment options: Speak to the dental clinic before treatment begins so you understand what costs you will be responsible for at the time of care.
Deposits: The dental clinic may incur various expenses in preparation for your child's treatment. In such cases, the dental clinic will require a deposit to cover some of these initial costs.
What does your plan cover?: It's important to understand what your dental plan covers and what costs you will be responsible for. Ensure you have this information available and confirm any changes before you visit the dentist. Ask your employer for a plan booklet; in particular, be aware of:
Plan limits: Does your plan have a yearly maximum based on a fixed dollar limit (i.e. $700 total coverage) or the frequency of services provided (i.e. units of scaling, or recall exams).
Percentage of coverage: What percentage of each treatment is covered? For instance, many standard dental plans will cover 80 percent for preventive dental services (exam, X-rays, cleanings, fillings) and 50 percent for other procedures (crowns, bridges, veneers and dentures). It is rare for a plan to cover 100 percent of services.
Fees covered for each procedure: Dental plans reimburse based on the plans fee schedule; this may differ from the fee your dentist charges. For instance, if your plan's schedule is $100 for a particular procedure (pays 80 percent of this fee) but your dentist charges $120 for the same procedure your dental plan will still only cover 80 percent of $100, or $80. You will need to pay any remaining costs, in this case $40.
The co-payment: This is the portion of the plan that you are responsible for paying. For instance, if your plan covers 80 percent of a procedure, you are responsible for the remaining 20 percent. You are responsible for any costs not covered by your plan.
Specialist fees: While some plans may reimburse specialist fees, it is rare. Your plan will only pay for the portion of the cost based on the rate at which they reimburse; you are responsible for any variations.
Lab fees: As part of your treatment your dentist may work with an outside lab. The lab sets its fees independently of the dental office; lab services may or may not be covered.
Dual coverage: You may be eligible for additional coverage if you are also covered under a spouse/partner's dental plan. In this case your dental plan provides the primary coverage while your spouse or partner's plan may provide some additional support. However, this may not apply if the two plans are with the same company.