Oral health is often considered the runner up behind medical benefits since proper hygiene can help prevent medical complications.
Group dental policies provide employees immediate access to benefits since most exclude waiting periods for services if there are a minimum of 10+ employees. If there are waiting periods for certain services, they may be waived with proof of prior coverage.
All preventive services such as oral exams, x-rays, and bi-annual cleanings are covered at 100%. Pediatric dental is embedded in all medical policies, meaning minimum essential care is available to children age 18 and under within their medical policy.
Dental policies are defined by their annual maximum, copays, network, MAC vs. UCR coverage, age limits, and additional riders such as orthodontic coverage.
- Annual Maximum: This is the dollar amount that you are entitled to receive as a benefit in any calendar year. The benefit resets every January, and it would also reset should a group switch carrier’s mid-year.
- Copays: This is the dollar amount associated with your dentist visit, and will vary between in-network and out-of-network.
- Network: Each carrier is contracted with x number of dentists. If your dentist is contracted with the carrier, they have agreed to a predetermined cost structure and would be considered in-network. If your dentist is not contracted with the carrier, your serves will be deemed out-of-network and will end up costing you more.
- MAC – Maximum Allowable Charge. When visiting an out-of-network dentist, each service has a predetermined cost associated to it, you would be liable for anything above said cost.
- UCR – Usual, Customary, and Reasonable. This coverage structure is accompanied by a percentage, typically ranging from 80-95% which means the allowable benefit is accepted by X% of dentists in your location. It is still possible to find a dentist that charges more than what is UCR in your area, for which you will be liable for the difference.
- Age Limits – This is typically associated with Orthodontic coverage. Some plans may only cover children up to the age of 19, whereas others may cover up to the age of 26.
While the information above covers most dental definitions in a nutshell, we look forward to simplifying the purchasing and claims process even further when the time comes.
The Employee Retirement Income Security Act (ERISA) oversees group benefit plans, and with the onset of the Affordable Care Act, the ERISA Summary Plan Description (SPD) requirements are in the spotlight.