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. See also: What is the dental plan co-payment?
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.
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. See also: How can I find out what my dental plan covers?
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.
Dual coverage is when you are covered by two separate dental plans, such as your own plan and a spouse's or a partner’s. 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. See also: What is the dental plan co-payment?
The details of your plan are protected by the Personal Information Protection Act (PIPA). 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 will cover and for what you will be responsible. 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.
Many dental plan carriers use the British Columbia Dental Association'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 BCDA 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. See also: What is the suggested fee guide?
Note: Professional dental organizations and dentists are not involved in any aspect of determining dental plan coverage.
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.
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. See also: What is a pre-determination?
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.
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 Information Protection Act (PIPA). 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. See also: How can I find out what my dental plan covers?
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.