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Family, Cosmetic & Restorative Dental Care
1400 Broad Street Bloomfield, New Jersey 07003
973 338-3101
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Dental insurance can be confusing. And to make matters even worse, every insurance plan handles things differently.

Dental insurance plans are a contract between you and your insurance provider, in many cases, coordinated with your employer. Our office has no control over this contract, but we do want to help make the information more clear.

There are several types of dental insurance, including direct reimbursement, preferred provider organizations, capitation, and indemnity plans.

Direct reimbursement plans

In direct reimbursement plans, your employer reimburses you directly for all or part of your dental treatment. Usually, all types of treatment are covered, and you can see any dentist you choose.

Preferred provider organization plans

These plans are also called dental health maintenance organizations or HMOs. In a preferred provider organization plan, you can choose any dentist, but the plan will pay a higher percentage of the fees if you choose one from a specific network of dentists who have agreed to discount their fees in order to be part of the plan.

Capitation plans

In a capitation plan, whether you visit the dentist or not, the plan pays participating dentists a set amount for each patient enrolled in the plan.

Indemnity plans

The most common insurance programs are indemnity or UCR plans. The initials UCR stand for “usual, customary, and reasonable.” In these plans, you may find a dentist of your choice, and the dentist is paid on a traditional fee-for-service basis.

You or your employer pays monthly premiums to the insurance company, and then the insurance plan pays 50 to 80 percent of their UCR fees, leaving you to pay 20 to 50 percent of the remaining UCR fees, plus any remaining fees that the insurance plan’s UCR fees don’t cover.

Most people assume insurance companies have gathered statistics and that these statistics are the basis for UCR fees. In most cases, this isn’t true. These UCR fees are usually not representative of local dentists’ fees. They are often fees arbitrarily set by the insurance company. In fact, it’s not unusual for the same insurance company to pay different UCR fees to the same dental office, depending on the plan purchased by different employers.

For the same reason, different insurance companies’ dental plans often have a different UCR for the same geographical area and for the same group of dentists.

The choice is yours

It’s very common for patients to choose dental treatment that their dental insurance plans won’t fully pay for.

Dental plans generally set which dental services will be covered and which will not. Many dental plans cover only lower quality materials and services, and these may not be the best treatment choice for you and your family.

And most insurance plans often exclude new treatments that they label as “discretionary,” even common treatments such as implants, porcelain veneers, white fillings, bonding, and whitening.

In addition, dental insurance coverage maximums just haven’t kept up with the times. Back in 1960, a typical annual maximum was one thousand dollars. Forty years later it still sits at approximately one thousand dollars, despite inflation and cost of living increases. To stay up with inflation, that one thousand dollars in 1960 would have had to increase to $5,816 dollars today.

For these reasons, you have a choice to make when it comes your dental care. In many cases, your insurance plan may want you to consider only the least expensive dental procedures, but we believe that you should be able to choose the best dental treatment and materials for you and your family.

1400 Broad Street Bloomfield, New Jersey 07003 — 973 338-3101