holland dental patients

Short answer: it depends. Employers negotiate plans with carriers, and often renegotiate those plans each year. The details are always fluid and changing. If you want to know the details of your dental benefits, you’ll probably need to ask your employer’s HR department.

Long answer: It depends. But here’s how the system works.

Dental benefits are a contract between a carrier and an employer. These benefits are a way of pushing pre-tax dollars to an employee to help offset the cost of dental care. Premiums are collected from employees as a payroll deduction and benefits are paid out through a carrier who acts as plan administrator. Depending on the situation, the carrier might send benefits to your dental provider, or might choose to send benefits directly to the employee.

The generosity of the plan is up to the employer. As a plan is negotiated, the employer will select an “annual maximum benefit” – the most that the plan will pay on behalf of any one participant in a single plan year. This maximum benefit has NOTHING TO DO with the conditions or needs of the participant. No matter how severe the disease or great the pain, when the maximum is met the benefit plan stops making any payment toward dental care. Generally, we see our patients have annual maximum benefits of between $1,000 and $1,500.

Fun fact: When Dr. Jeff’s father started practicing dentistry in 1972, the typical annual maximum was $1,000. If that had kept pace with inflation, then a typical plan in 2023 would have a maximum of more than $7,000 per year! Think this is confusing? Let’s talk about copay percentages. Copays are a financial tool used by insurance plans to make consumers cautious about using benefits. Twenty years ago, a friend of Dr. Jeff had a vision plan that completely covered new prescription glasses every year. And every year, his friend and his family would get new prescription glasses – even though their prescriptions hadn’t changed. It was free – why not? Copays make treatment “not free,” which reduces the rate at which people use benefits (and also reduces the amount of money paid out by an insurance carrier.)

Those copays are also negotiated between employers and carriers. Some procedures will be covered at a higher rate than others. All procedures will have an allowance cap (confusingly called a ‘UCR’) applied to them as well – which means that for any given procedure, there’s a maximum benefit that plan will pay.

Here is a silly example. Let’s say your employer offers a “restaurant benefit.” We know that it takes a lot of food to feed a person for a year, but your benefit has an annual maximum of $500. Also, the restaurant benefit carrier doesn’t want everyone to run out to the fanciest restaurant they can find and spend it all at once. So they create a copay system that covers 100% of the cost of salads, 80% the cost of lean meats, 65% of the cost of fish (also healthy, but more expensive than fish or pork), 50% of the cost of red meats; 25% of the cost of a dessert, 10% of the cost of non-alcoholic beverages and nothing for alcohol. However, there are a lot of cuts of steak available, and a lot of different restaurants you could choose, so they set a UCR cap of $30 on a steak. You may go to any restaurant you like, and choose any steak on the menu, but the most the carrier will pay toward your steak is $15 (50% of the $30 steak maximum).

Dental benefits are confusing. The clauses and restrictions in the contracts have less to do with patient health and more to do with controlling the flow of money around the system. In most cases, the best advice is to decide with your dental care team what treatment is appropriate for you based on your own health goals – and then to ask your team to help you get whatever benefits you may be entitled to receive from your plan.