What constitutes a covered benefit?
A covered benefit refers to a dental treatment that is recommended by a dentist, listed on the fee schedule, and accepted within the terms of your group’s insurance plan.

What is considered optional treatment?
Optional treatment encompasses procedures that are either not listed on your fee schedule or go beyond the minimum required to restore the tooth to its original function.

How do indemnity, PPO, HMO, and discount insurance plans differ?
Indemnity or Traditional Insurance reimburses members or dentists based on the dentist’s UCR (Usual, Customary & Reasonable fee). This allows subscribers the freedom to visit any dental office without being limited to a specific panel.

PPO (Preferred Provider Organization) insurance is the most common type. It provides a list of participating dentists from which members can choose. These dentists have agreed to a lower fee schedule, resulting in cost savings for patients. PPO plans usually cover 50% of major treatments, 80% for basic care, and up to 100% for preventative services. Annual maximums typically range from $1,000 to $2,000.

HMO (Health Maintenance Organization) insurance, also known as capitated or prepaid insurance, offers basic care at a lower cost. Participating providers receive a monthly capitation payment for assigned patients to cover administrative expenses. HMOs generally do not cover services rendered, and patients are responsible for paying the dentist directly. Fees are typically significantly reduced under HMO plans.

Discount insurance plans provide discounted rates for dental services through a network of participating providers. Patients pay reduced fees directly to the dentist at the time of treatment, without the need for insurance billing.