What is a dental preferred provider organization (dental
PPO) plan, and how does it work?
A
dental preferred provider organization (dental PPO) plan
works for you in two ways: through a panel or network of
participating dentists, or through dentists you select that
are not in the network. Each time you or a covered family
member needs dental care, you choose whether to see an in-network
or an out-of-network dentist.
In-network dentists are listed in your plan's provider directory.
When you use an in-network dentist, also called obtaining
dental services in-network, your costs tend to be lower,
because the dentists and the network have negotiated to
have the dentists accept certain fees for certain services.
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With a dental PPO plan, do I name a primary dentist?
The
dental PPO plan does not require you to name a primary care
dentist or coordinate your care through a particular dentist.
However, you are free to choose a primary dentist, whether
or not that dentist participates in the network.
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What are the advantages of obtaining my care from in-network
dentists?
| There
are several advantages when you go in-network. Generally:
|
| • |
You
don't need to pay a deductible, or your deductible is
lower than when you go out-of-network. |
| • |
You
don't need to submit claim forms and wait to be reimbursed
by your plan. |
| • |
With
some plans, you pay a smaller percentage of coinsurance
when you go in-network. |
| • |
With
other plans, you only pay a copayment (fixed dollar
amount) at the time you receive covered services. With
these plans, after you pay your copayment, you owe no
more payments for the covered services. |
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How does the dental PPO plan work when I go out-of-network?
| Generally,
you may use any covered dentist you choose. However,
your cost will generally be higher and you have certain
added responsibilities. For example: |
| • |
Each
year, you must pay part of your eligible out-of-network
expenses before the plan begins to pay benefits. This
amount is called the deductible. |
| • |
After
you satisfy the deductible, the plan will reimburse
you for a percentage of your eligible expenses and you
will pay the balance. The percentage you pay is called
your coinsurance percentage, and may be higher than
for in-network services. |
| • |
You
must complete claim forms and file claims with the dental
plan to receive payment of benefits. |
| • |
The
plan will not cover any charges above the allowable
amount. |
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When do I need to file a claim form?
You
may not need to file a claim form when you see in-network
providers.
When you do need to file a claim form, as you need to do
in most cases when you go out-of-network, your dentist may
handle your expense in one of two ways. Most dentists require
you to pay the bill right away. In this case, get a receipt
and file it with a claim form to be reimbursed. If the expense
is covered, you will be reimbursed for part of the bill.
To file a claim, follow the instructions on the claim form.
If you have more than one health or dental insurance plan
and have received an Explanation of Benefits (EOB) form
from another plan, be sure to include a copy with your claim.
Sometimes dentists are willing to wait for payment. In this
case, you or your dentist will file the receipt and completed
claim form with your dental health care company. The dental
health care company will pay the dentist for the part of
your expense the plan will cover. The dentist will then
bill you for the part the plan did not pay.
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What happens if I need dental care while I'm traveling?
If
you need dental care while traveling, call member services
for your dental plan at the number on your ID card. Member
services can refer you to an in-network dentist.
In a dental emergency such as an accident in which you lose
teeth or extreme dental pain, contact member services if
you are able and the dental plan can help you decide where
to go for care. However, even if you are unable to contact
member services, get the care you need. Even if you need
to go out-of-network, your plan may cover emergency care
at in-network benefit levels as long as you follow the plan
rules.
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What is a deductible?
A
deductible may only apply, or may be higher, when you obtain
care out-of-network. A deductible is the part of eligible
expenses you must pay before the plan begins to pay a percentage
of your eligible expenses.
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Are there expenses that don't count toward my deductible?
Yes.
Some of your expenses will not count toward your deductible.
For example, amounts your dentist charges above the plans
allowable amount for a given service will not count toward
your deductible.
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What is coinsurance?
Coinsurance
may only apply to out-of-network care. After you satisfy
the deductible, the plan will reimburse you for a percentage
of your eligible expenses for out-of-network care and you
will pay the balance. The percentage you pay is called your
coinsurance percentage.
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What is a copayment?
If
your plan has copayments, the copayment generally applies
to in-network care. With this type of plan, when you obtain
care from an in-network provider, you pay only a fixed amount
at the time you receive services. That amount is called
your copayment.
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What is predetermination of benefits?
Predetermination
of benefits is the process by which a dental care company
reviews the proposed treatment and tells you and your dentist
how benefits may be paid.
It's a good idea to obtain a predetermination of benefits
before expensive services are performed. Have your dentist
complete a form showing the proposed treatment and submit
it to your dental care company. The dental care company
will send your dentist an explanation of what benefits would
be covered and what you would have to pay out of your pocket.
You can then discuss your treatment options with your dentist.
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What's the amount known as the "allowable amount,"
the "U&C amount" or the "R&C amount"?
The
terms "allowable amount," "U&C amount"
or "R&C amount" vary by plan but refer to
the same thing. The allowable, usual and customary or reasonable
and customary amount is the amount usually charged for a
given service by most providers in your area. This amount
is determined by your dental care plan. If your dentist
charges you more than this amount, you will not only be
responsible for your deductible and coinsurance, but also
for the entire difference between the U&C amount and
the amount your provider charged. This concept only applies
for out-of-network care, because PPO dentists have agreed
to accept negotiated fees, which are by definition allowable
amounts.
For example, suppose you receive a service for which the
"U&C amount" is $100 but your dentist charges
you $110. The dental care company will multiply the percentage
the plan pays for that service by $100. So even if the service
were covered at 100%, you would pay the $10 difference ($110
charge minus $100 U&C).
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What are covered services?
Covered
services are services covered by the plan. No dental plan
covers everything. If you obtain services that are not covered
services, you pay the full cost for those services.
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What is an out-of-pocket maximum?
An
out-of-pocket maximum is the most you would have to pay
out of your own pocket for eligible expenses. Not all plans
have an out-of-pocket maximum. Check your Benefits Summary
for details. With a plan that has an out-of-pocket maximum,
once you reach the out-of-pocket maximum for a given year,
the plan would pay all eligible expenses for covered services
until any lifetime maximum benefit is reached.
Not all expenses count toward an out-of-pocket maximum.
Expenses for services that are not covered under the plan
and amounts over any allowable amount limit would not count
toward your out-of-pocket maximum.
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What is a lifetime maximum?
A
lifetime maximum is the most that will be paid by the plan
for covered services for a given plan member. Not all plans
apply a lifetime maximum, and some plans have different
lifetime maximums for different services or for in-network
and out-of-network services. Once you reach the lifetime
maximum, you pay all expenses over that amount.
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