With more than 30,000 different dental benefit plans in Ontario, there is no one-size-fits-all approach. Your benefits provider and/or employer will provide you with information about your coverage.
Your dentist is your partner in taking care of your dental health. He or she will discuss your treatment options considering both your clinical and financial needs, helping you to make decisions about your oral health care. While it is important to understand your dental plan, it is also important to make choices about treatment based on all available information.
Dental insurance basics
Some patients will buy their own dental plan, but most have dental benefits provided by their employer. When your employer chooses your insurance plan, they consider things like the plan’s cost and how often employees use their benefits.
Although they choose the plan, your employer is not responsible for administering your dental plan. Instead, they enter into a contract with an insurance company who then acts as your dental plan administrator. Your dental plan administrator must reimburse you based on the terms of the dental plan contract.
Dental plans vs treatment plans
A dental plan is usually part of a health benefits package you get through your workplace. It can also be purchased on its own. Dental plans define which treatments are eligible for reimbursement.
A treatment plan is a personalized approach you and your dentist develop to treat your dental health needs. It serves as your roadmap to good oral health and should not be limited by what your dental plan covers.
Keep in mind that all benefit plans have limitations. Even though treatment may be necessary, it is not always covered in your dental plan.
Your responsibilities
Patients with dental insurance are asked to be sure to provide full details of their insurance information prior to their appointment. This information includes:
- Employer
- Insurance company
- Policy-holder
- Policy-holder’s date of birth
- Plan number
- Division number
- Patient’s date of birth
- Patient’s relationship to policy-holder
Our account managers are familiar with many dental plans and can provide patients with some information. However, there are thousands of dental plans, each with unique arrangements and it is up to you to obtain details about your plan from your human resources department or dental plan administrator.
What you should know about your plan
- What is covered each year?
- Is there a deductible?
- Is there a total dollar limit on my coverage?
- Can I choose a procedure other than the one my plan covers?
- Will I still be covered if I change jobs?
- How much am I covered for cleanings and X-rays?
- How much am I covered for fillings and root canals?
- Are other treatments like bridges and crowns, dentures, and oral surgery covered and at what rate?
Typically, dental plans only cover a percentage of the claim amount. It is the patient’s responsibility to pay the remaining percentage not covered by his or her dental plan.
Your dentist’s responsibilities
While planning your treatment, your dentist will discuss the details of the proposed procedures, the associated risks, benefits, and estimated costs. The dentist only proceeds with treatment once informed consent is obtained. In complex cases, dentists will include a discussion of subsequent treatments too. Our dentists strive to be clear, open, and upfront about the actual costs that are involved with any treatment plan.
Sometimes, your dental plan coverage and your preferred treatment plan do not align. Your dentist will help you to understand your options and the associated risks and costs. If your dental plan only covers part of the cost of your treatment plan, you will be responsible for the difference.
Our office will submit an estimate (pre-determination) to your insurance company on your behalf. Once the insurer provides specific details of your coverage, the dentist will review the information with you to help you make the best decision for you.
