the simple guide to group dental plansalwayscarebenefits.com/comm/...group-dental-ebook.pdf ·...
TRANSCRIPT
What benefits can build.SM
The Simple Guide to
Group Dental Plans
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Introduction ................................................ 3
Types of Dental Plans ...............................4
Examples of Dental Plan Coverage ........ 5
Plan Options at A Glance ......................... 6
Glossary ....................................................... 7
A Look Inside
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Going to the dentist can be costly, and you may be wondering if dental insurance would help. The plans featured in this guide are typically available through employer groups and/or direct to consumers, However, you may find that your employer’s plan offers a lower premium, richer benefits, a larger provider network, and/or other features that individual plans in your area do not. This eBook will help you understand and choose the right fit for you.
Introduction
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What are the different types of dental plans? PPO Plans
A Preferred Provider Organization plan (PPO plan) provides a dental plan with a network of dentists who have agreed to accept a specific level of payment for covered services. If you choose a provider in the PPO network, you receive the benefit of the negotiated fee. If you go out-of-network to a non-participating provider, claims will be paid according to the plan and balance billing may occur.
It’s important to remember that this plan will usually cover preventive services in full when an in-network dentist is used. If a covered patient visits an out-of-network dentist, members will pay a percentage of the discounted rate (coinsurance). Additionally, patients who choose a PPO plan will need to be mindful of their annual maximum, any deductibles, coinsurance and waiting periods that will need to be met.
MAC Plans
The maximum allowable charge plan takes advantage of your plan’s dental network. When you choose an in-network dentist (who has agreed to network rates) you are only responsible for any applicable coinsurance and deductible; there is no balance billing. If you see an out-of-network dentist with your MAC plan, insurance will only cover the network rate amount. The dentist may bill you for the difference between that rate and the amount they charge for the procedure, and you will pay any difference, plus any applicable coinsurance and deductibles. With its typically lower premiums and out-of-pocket costs, a MAC plan may be right if your dentist is in-network.
Schedule Reimbursement Plans
A schedule reimbursement plan (or “fee schedule” plan) provides a fixed price list for dental procedures. This type of coverage pays a flat dollar amount per covered dental procedure outlined in the policy. Members can visit any provider, and the carrier will pay the lesser of the provider’s actual charge or the amount listed on the schedule of covered dental procedures.
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The Qualified Dental Plan (QDP), like other federally approved dental plans, includes the required pediatric dental essential health benefits (EHBs) for dependents age 18 years or younger. As with other dental plans, covered patients pay less when they use in-network providers. You can use dentists outside of the network for an additional cost. For children age 18 years and younger in-network dental plans feature no annual limits and an out-of-pocket maximum. Choose this plan for child-only, individual-plus-child, or family dental coverage.
*Plans, benefits and rates may vary by state.
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How much will it cost to go to the dentist?Examples of In-Network Dental Plan Coverage
(New Orleans 70112)
Without Insurance = $77.50
PPO/MAC Plan = $0.00
Schedule Reimbursement Plan = $1.00
Without Insurance = $1,071.00
PPO/MAC Plan = $342.00
Schedule Reimbursement Plan = $447.00
Without Insurance = $143.00
PPO/MAC Plan = $14.80
Schedule Reimbursement Plan = $18.00
Comprehensive Oral Evaluation (Class A)
Porcelain Crown Fused to High Noble Metal (Class C)
Single Surface Silver Filling (Class B)
Illustrations are for identical MAC and PPO plan designs only. Deductibles, coinsurance and copays may apply. Please be sure to review the certificate of insurance and it’s classification of services.
Get Your Local Dental Rates, Here!
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AlwaysCare Standard Plan Options at A Glance
1 - Some in-network providers are allowed by state law to opt out of noncovered service discounts.2 - EHB services are in-network only.3 - In-network only4 - Medically necessary orthodontics only.
PPO PlansFee Schedule
PlansMAC Plans
Federally Qualified
Dental Plans (Adults)
Federally Qualified
Dental Plans (Children Only)
Access to Network Providers
In-network Discounts1 Out-of-network Providers Allowed 2
Preventive Services Covered in Full 3 Coinsurance for Basic & Major Services Subject to Annual Maximum Benefit Subject to Deductibles Flat Reimbursement Paid Per Service Waiting Periods for Preventive Services
Waiting Periods for Basic & Major Services Optional Orthadontics Coverage (Children) 4
The eBook is not a contract of insurance. Products and provisions not available in all states. Please note: This is a brief description of the AlwaysCare Benefits product offerings. It should
be used only as a guide. It does not contain complete plan details; plan details may vary.
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Glossary Annual Maximum: The maximum dollar amount a plan will pay out for care for a specific benefit period, typically 12 months. Balance Billing: When a dental provider bills you for the difference between their charge and the carrier’s regional discounted rate.
Beneficiary: A person eligible to receive benefits under a dental plan.
Carrier: Any insurer, managed care organization, or group hospital plan, as defined by applicable state law.
COBRA: Federal legislation regarding the continuation of health benefits for all types of employee benefit plans provided by the employer.
Co-insurance: The arrangement between the insurance carrier and the insured in which you pay a specified percentage of covered expenses.
Copay: A fixed dollar amount that you must pay at the time your service is rendered.
Deductible: A dollar amount you must pay for covered services before your plan begins to pay benefits.
Dependents: Spouse or child of an insured person who is eligible for dental insurance coverage. Eligible dependents may vary by state.
Exclusions: Specific conditions, services or treatments for which your plan will not provide coverage. Maximum Allowable Charge: The maximum dollar amount a dental program will pay toward the cost of a dental service as specified in the program’s contract provisions.
Maximum Benefit: The maximum dollar amount a dental plan will pay toward the cost of dental care in a given period.
Missing Tooth Clause: States that benefits are not payable to replace a tooth that was extracted prior to having dental coverage.
Pre-treatment Estimate: A written estimate of benefits available as of a specific date and time, given to a member or treating dentist in advance of proposed treatment.
Preventive and Diagnostic Services: Dental procedures concerned with the prevention of dental diseases by protective and educational measures (e.g. exam, cleanings, X-rays and fluoride).
Waiting Period: A stated period of time that a member must be enrolled in a plan before being eligible for benefits or for a specific category of benefits.
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