Contrary to popular belief, dental staff do not know which dental procedures are covered under your plan, and which are not. Your dental plan is a contract between you and your insurance carrier. You, the patient, are responsible for educating yourself about such things as:
- procedures that are covered by your plan
- to what extent or percentage of the actual cost they are covered
- annual maximums in your plan
If you do not already have a booklet explaining your dental benefits, ask your employer for one and ask them to explain it to you. If necessary, take your booklet to your dental office where staff will be happy to help you understand your plan.
Dental insurance carriers consider the details of your plan to be private since the Privacy Act was introduced in 2004, and will no longer release information about your plan to a dentist or dental office staff.
Why is this important to know?
If you have treatment and:
- there is no coverage under your plan contract; or
- your coverage has run out because you have exceeded the yearly limit of your plan; or
- your dentist's fees for a procedure exceed the amount covered by your plan; or
- your coverage has expired you will be responsible for payment of the treatment.
A note about the fee guide – The BC Dental Association (BCDA) produces an Annual Suggested Fee Guide for Dental Treatment Services, effective February 1st of each year
Most, but not all, plans will cover costs based on the fee guide. It is important to note, however, that it is not mandatory for dental offices to follow the fees suggested in the fee guide. A copy of the current fee guide can be viewed at most larger municipal libraries.
Patients should request a written treatment plan and estimate of costs before treatment starts. Since your plan may follow the BCDA fee guide fees, you may want to know whether your dentist's fees vary from the guide. This will provide you with a more accurate estimate of what proportion of the total cost will be covered by your dental plan, and how much you may be required to pay personally.
Most dental plans will cover a set percentage of the cost of treatment. This will vary but the most common levels of coverage are 50%, 70%, 80%, and 100%.
It should be noted that plans that claim to cover 100% in reality seldom do. Inevitably, there will be an item of treatment that will not be covered at 100% - perhaps not at all.
The most common plan breakdown:
- Schedule A, basic: 80% - will usually include exams, x-rays, cleanings, fillings and possibly root canals
- Schedule B, major: 50% - will include such things as crowns, bridges, veneers, dentures.
- Schedule C:, orthodontic: 50% (or perhaps a set lifetime limited cash amount)
Please note: Very few plans will cover the surgical part of implants, although some may cover a portion of the cost of the prosthesis (crown or bridge) that goes on top of the implant.
See Assignment of Benefits for information on the options that dental offices employ in billing your plan.
The patient is responsible for the payment of your dental treatment. If an insurance plan is in place it should be considered as an aid to help you cover part of the costs. You, the patient are responsible for any part of the fee not covered by your insurance plan.
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