7 ways to help patients understand their dental plan [VIDEO]

June 3, 2013
Issue 6

It is important for the patient to know the limitations of their plan in order for us to help them and help you resolve claims.

It is important for the patient to know the limitations of their plan in order for us to help them and help you resolve claims.

Here, we go over some of the contract limitations and exclusions found in various plans and why you need to explain them to your patients.

 

Coverage year: Standard coverage years are calendar or fiscal. Some unions and schools, for example, set the coverage year fiscally from April 1 to March 31.

Maximums: Yearly maximum dollars allowed each year can vary from $500, $750, $1000 and possibly more.

Effective date: Knowing the effective date of coverage is important because it coincides with any waiting periods on dental treatment.

Waiting periods: Knowing the waiting period for certain procedures is important so that the patient has a more accurate determination of out of pocket expenses. For example, if the patient has a crown diagnosed but there is a 12-month wait for major dentistry then, the patient’s out of pocket would be 100% instead of the standard estimated 50%.

Frequency limitations: It’s good to know frequency limitations for certain procedures. The standard frequency limitations written on most contracts are preventive frequency. The most common preventive frequency is: preventive visits covered two times per year or each six months.  It is vital to clarify when the coverage frequency limit is listed as two times per year.  Does this mean two times in a calendar year or two times in a 12 month period?

Percentage or fee schedule?: Typically, there are two types of dental plans, ones designed to pay a percentage of an allowable fee and the other, designed to pay according to a fee schedule. 

Non-Duplication Clauses: The standard definition of “non-duplication clause” is this:  If a patient is covered under two plans and primary pays 80% of the claim, the secondary will not duplicate the benefit. So, if the secondary benefit is also 80%, the secondary plan will pay nothing. 

By helping educate your patients about their dental benefit plan, you are increasing your practice’s effectiveness.