NB Dental
Your Oral Health

Understanding Dental Insurance

What does a basic dental plan cover?

Most dental plans cover only a specific percentage of the cost of eligible dental treatment services (services included in the plan); the patient is responsible for the remainder along with any costs not covered by the plan.

For example, many standard dental plans will cover 80 percent of basic/preventive dental services such as dental exams, X-rays, cleanings, fillings and root canals while coverage for other procedures such as crowns, bridges, veneers and dentures may be at 50 percent. Other plans may cover a higher or lower percentage of services; it is rare for any plan to cover 100 percent of every service. You should also be aware that most dental plans have a financial limit and may even use rates from a previous year’s suggested fee guide.

While your dentist can help you understand your plan coverage they are not experts on your plan. It is your responsibility to know the details of your plan.

Will my dental plan cover seeing a specialist?

What is covered will depend on your plan. Some dental plans may base the percentage of treatment covered on a specialist's fee, others may only use general practitioners' (GP) fees while some may provide an enhanced level of coverage, such as 10 percent above a GP fee.

Review your plan booklet for details on your plan.

What is dual coverage?

Dual coverage is when you are covered by two separate dental plans, such as your own plan and that of a spouse or partner. It is likely that one plan provides the primary coverage while the second provides some additional support. This does not mean that you will always have 100 percent coverage. Dental plans generally cover a percentage of treatment and the patient is responsible for the remaining portion — the co-payment. This is particularly true if both you and your spouse/partner are covered by the same plan.

How can I find out what my dental plan covers?
How can I change my dental plan?

The details of your plan are protected by the Personal Health Information Privacy and Access Act (PHIPAA). While your dentist can help you understand your plan, they do not know the details of your plan and/or any changes that may occur.

Employer plan: If your dental plan is part of an employee benefits package, ask your employer and/or human resource manager for a copy of the plan booklet. You should also speak to them about any questions related to your plan and/or any recommendations you may have for changes to your plan.

Individual plan: If you have and/or are purchasing a private dental plan ask the dental plan provider about available plans outlining what they cover and what will be your responsibility. When choosing a plan look carefully at what you will be required to pay and what treatment will be covered. Ask your dental plan provider for a copy of the plan booklet.

Many plans also post information online. Ensure that you have the correct information to be able to access these details. Also ensure that you are aware if any changes to your plan occur prior to any dental appointments and/or treatment.

How do dental plan carriers determine coverage?

Many dental plan carriers use the New Brunswick Dental Society’s suggested fee guide as a reference to determine plan coverage. They choose treatment services and base the percentage of plan coverage on the fees outlined in the guide. They do not always use the most current guides; in some cases coverage is based on fees outlined in a previous year's guide (going back a year or more). In addition, dental plan fee schedules may not include all the codes in the current NBDS guide.

Dentists are not required to follow the fees outlined in the suggested fee guide or the fees outline by dental plan providers. Any costs not covered by the plan are the patient's responsibility.

Note: Professional dental organizations and dentists are not involved in any aspect of determining dental plan coverage.

Why does my dental plan only cover a selection of treatment?

Dental plans are developed to offset some of the costs of treatment and generally include a selection of coverage; they are not developed based on your unique dental care needs, nor do they cover the full range of dental treatment services available.

Dental plans are selected by the plan purchaser, usually as part of a group benefits plan. Many plans will cover a range of diagnostic (examination) and preventive services (scaling, polishing). Such services are common to all patients and aid in the prevention of dental disease. Bear in mind that these plans may also have limits on the amount or frequency of services and treatment which is not based on what any individual may actually need. Additional treatment services will vary, as will the percentage of coverage patients receive for treatments covered by the plan.

Why can't my dentist create a treatment plan based on my
dental plan coverage?

Your dentist's first obligation is to your health. If you have an issue with your mouth your dentist will present treatment options to meet your oral and overall health needs; your treatment plan is not based on your dental plan coverage. Your dentist can help you to get a pre-determination for treatment to understand what costs may be covered by your dental plan.

It is important to make your treatment decisions based on your health care needs, not based on what your dental plan covers. Speak to your dentist about his or her treatment recommendations and cost estimates along with any consequences in delaying or refusing treatment so you can make an informed choice for your health.

Why doesn't my dentist/dental office know what my plan covers?

There are many dental plan options available. Plan coverage is determined by you and/or your employer. The details of your plan are protected by the Personal Health Information Privacy and Access Act (PHIPAA). While your dentist can help you understand your plan, they do not know the details of your plan and/or any changes that may occur.

It is your responsibility to understand what your plan covers. It is important to be aware of any financial limits and changes to your plan.

Do I need a dental plan?

If you do not benefit from a dental plan provided by your employer you may wish to consider purchasing a dental plan to help offset some of the costs of care. This is particularly valuable in accessing preventive services.

Many plans include a range of diagnostic (an examination by a dentist) and preventive (scaling, polishing) treatment services, generally covering a higher percentage of the associated costs. Such services can aid in the prevention of dental disease, identify trouble signs early and lead to less complex and costly treatment in the future. In considering a dental plan you may want to determine whether the annual cost of the premiums are preferable to simply budgeting for dental care.

What is the dental plan co-payment?

The co-payment is the patient's portion of the cost of care. Dental plans are a benefit designed to offset the cost of dental care. Generally a dental plan will only cover a portion of the cost of any treatment service—the patient is responsible for any costs not covered by the plan (the co-payment).

Your dentist has a legal and regulatory requirement to collect the co-payment from all patients.

How much do I have to pay?

This will depend on your plan coverage. Many plans will cover a percentage of costs for eligible services. For example a plan may cover 80 percent of the cost of basic/preventive services such as examinations, fillings, and cleanings. This percentage is based on the costs outlined by the plan provider and may vary from the actual costs of the treatment. Major procedures such as crowns, bridges, and dentures may be covered at 50 percent of the cost outlined by the plan. You are responsible for any costs not covered by the plan.

Review your dental plan to understand your coverage.

Why do I have to pay the co-payment?

You dental plan is an agreement between you and your dental plan company that they will cover a percentage of the eligible treatment based on the details outlined in your plan. Both you and your dentist sign a claim to agree to the total cost of treatment. If you are not paying your share of the agreement you are making a false declaration, as is the dentist.

A dentist must accurately reflect the percentage of the total cost that is being charged to the insurance company and collect the remaining costs from the patient

What is a pre-determination?

A pre-determination is an estimate of what treatment your dental plan will cover and what you will be responsible for. Your dental office will submit an outline of the proposed treatment to your dental plan provider prior to proceeding with treatment. It is an estimate only and does not guarantee the final costs you will be responsible for paying.

It is important for you to be well informed on your plan coverage. Check with your dental plan provider to clarify when a pre-determination is required. Some plans may only reimburse some services if a pre-determination is received in advance of treatment. Also be aware that pre-determinations may be valid for a limited time; what is covered can change if you reach the financial limits of your plan; and/or other changes can occur to your plan before treatment is completed.

The final treatment coverage is determined by your dental plan carrier. Any costs not covered are your responsibility.

My dental office tried to get a pre-determination for treatment;
why did my dental plan provider decline it?

There are many reasons why a pre-determination may be declined. You may have reached the coverage limits in your plan or the treatment outlined may not be covered by your plan—the treatment plan is based on your health needs, not your plan coverage.

It is important to understand that even if a pre-determination is approved, this is not a guarantee of coverage. Any costs not covered are your responsibility to pay. Review your plan coverage, and speak to your dental plan provider if you have any concerns.

What can I do to avoid any unforeseen dental costs?

Understand your dental plan. Know what coverage you have so that you can make informed decisions on what dental treatment services are covered and what treatment costs you are responsible for. Speak to your dentist about the treatment options and the importance to your health so you can make an informed choice for your health needs.

Your dental office can work with you to provide an estimate and obtain a pre-determination prior to proceeding with treatment; however, they are not experts on your plan. Ensure you are aware of any changes and/or limits to your coverage and have let your dental provider know.

Prevention is the best way to maintain good dental health and reduce the need for more costly and complex treatment in the future. Practice good oral hygiene at home and visit the dentist regularly to identify issues early.

What is assignment and non-assignment of benefits?

As a service to patients, a dental office may accept assignment of benefits meaning they agree to have the patient request that his or her dental plan provider pay the dental office directly for the percentage of the cost covered. The patient is responsible for paying the co-payment when treatment is provided.

In a non-assignment office, the patient is responsible for paying the full cost of treatment at the time it is provided. The dental office will assist the patient by providing a completed dental claim form that the patient can submit to their dental plan provider for reimbursement.

In some cases, a dental plan company will only reimburse the plan holder, requiring the patient to pay for all costs at the time treatment is provided. In all circumstances, the patient is responsible for any costs not covered by his or her dental plan.

Why do I have to pay for treatment when it's covered by my plan?

Dental offices are entitled to reimbursement for services at the time treatment is provided. A dental plan is a contract between a patient and/or their dental plan carrier. As a service to patients, some offices will accept “assignment of benefits” whereby they agree to accept payment for the covered portion of treatment directly from the dental plan provider. Dental offices are not obligated to do so, and in some cases, are restricted from doing so as the dental plan carrier will only reimburse the patient.

The details of a patient’s plan are protected by the Personal Health Information Privacy and Access Act (PHIPAA). Due to the restrictions of a dental office in knowing what is covered by their patients' plans, they may choose to have the patient pay them directly for all services. While the dental office will help with the claim, it is the patient's responsibility to know what is covered in their plan including any limits to the plan or changes; to pay for any costs not covered by the plan; and to seek reimbursement from their dental plan provider.

Why has my dental office asked for a deposit for treatment?

The dental office may incur various expenses in preparation for the commencement of your dental treatment. It is not uncommon for dental offices to request a deposit prior to treatment.