According to the 2010 Canadian Health Measures Survey, 62% of Canadians have a dental plan, but many don’t realize that group plans aren’t designed to meet individual health needs. “Dental plans are a valuable component of extended health benefits and are designed to offset the cost of dental treatment,” says Dr. Hank Klein, president of the British Columbia Dental Association (BCDA). “Understanding how dental insurance plans work can help patients make informed choices in partnership with their dentist or dental specialist.”
Just like your physician, your dentist or dental specialist is highly trained. Treatment recommendations are based on your dental health needs, not dictated by your dental coverage. A dental plan is a contract between a third party (like your employer), and the insurance company. The procedures and percentages covered are determined by the contract, not your dentist.
Your dentist can help you understand your coverage and assist you in getting pre-authorizations for treatment. This will provide you with a good estimate of what will be covered by your plan, and what you will have to pay-before the treatment starts.
Coverage varies among dental plans
Your dental plan coverage is part of your benefits plan, not based on your (or your family’s) dental care needs. Every dental plan is different. Coverage varies based on what services are covered in the contract; percentage of fees covered for each service; and yearly maximums. It is the plan purchaser, such as your union or employer, who determines what is covered when they purchase your plan-not your dentist.
Dental office staff are not experts on your plan. It is your responsibility to know your plan coverage, including any changes. Ask your benefits manager or insurance provider for a plan booklet or information on your specific coverage.
The co-payment (deductible)
Regardless of the actual costs, most dental plans cover between 50% to 80% of the cost of dental care. Any portion of the price not covered by your plan must be paid by you, and is referred to as the co-payment (the same as the deductible on your car or home insurance). The claim form submitted to your insurance company is a contract. Your dentist or dental specialist has an ethical and legal obligation to collect the co-payment from you.
As a service to patients, some dental offices bill the insurance company directly for the covered portion of treatment. Dentists are not required to do this. The full cost of the procedure, including the co-payment (or deductible) or the cost of any services not covered in the plan, must be collected from the patient at the time the treatment is provided.
How are dental costs determined?
The BCDA produces an annual suggested fee guide for dentists and dental specialists in B.C. The majority of insurance plans base coverage percentages on this guide.
Dentists and dental specialists in Canada usually follow a fee schedule and set their prices to cover: lab costs and quality materials required for your procedure paid directly by the dentist; salaries; rent; mandatory continuing education; equipment; and all the related costs in running their dental practice.
Be an active participant in your dental health:
- Know your dental plan and what’s covered before your dental appointment to understand your portion of costs.
- Plan for the future. Consider all your extended health costs when planning for your retirement.
- Discuss all treatment options with your dentist to make an informed decision based on your dental health needs.
- Pay the required co-payment. You expect your dentist or certified specialist to be honest with you about the care you need, and so does the insurance company.
- Prevention is still the best treatment for everyone in your family: brush and floss daily; limit sugary drinks and snacks; don’t smoke; and have an examination by a dentist at least once a year to diagnose problems before they become more complex and costly.