Almost all dental insurance companies use what is called a Usual, Customary, and Reasonable (UCR) fee guide. This means that they set their own price that they will allow for every dental procedure that they cover. This is not based on what a dentist actually charges, but what the dental insurance company wishes to cover. For example, your dentist may charge $78 for a dental cleaning, but your insurance company will only allow $58 because that is the UCR fee that they have set.
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The cost estimates provided may be different from your actual costs for several reasons, including but not limited to, your unique dental circumstances and the decisions made by you and your dental professionals as to what services you will receive, deviations between the anticipated scope of services and the services actually provided, and the characteristics of your particular plan.
One of their popular plans is the My Dental Plan that allows you to customize your plan for what you need. It has a $50 deductible per person. You can customize the plan for either one or two cleanings per year and choose to have preventative care covered at 80% or 100%. When it comes to basic care, they offer the choice of 50% coverage and 80% coverage. For major car, they cover either 50% or 0% depending on the plan you choose. Their annual maximums are either $500, $1,000, or $1,500.
Unfortunately, Original Medicare (Parts A and B) does not include coverage for services like dental exams, cleanings, fillings, crowns, bridges, plates, or dentures. There are some exceptions, such as when a hospital stay is involved, but otherwise, you would have to pay out of pocket for any routine dental services. For some of us, those expenses could add up quickly.
Generally dental offices have a fee schedule, or a list of prices for the dental services or procedures they offer. Dental insurance companies have similar fee schedules which is generally based on Usual and Customary dental services, an average of fees in an area. The fee schedule is commonly used as the transactional instrument between the insurance company, dental office and/or dentist, and the consumer.
No individual applying for health coverage through the individual Marketplace will be discouraged from applying for benefits, turned down for coverage, or charged more premium because of health status, medical condition, mental illness claims experience, medical history, genetic information or health disability. In addition, no individual will be denied coverage based on race, color, religion, national origin, sex, sexual orientation, marital status, personal appearance, political affiliation or source of income.