Your employer will provide you with details of your plan that are easy to understand. It will give you a brief overview of the services that are covered, limitations and exclusions, and the fee guide used to calculate benefits. Keep in mind that this page offers a brief summary and the actual specifics of the plan will be spelled out in a contract between the employer and the dental plan administrator.
The employer enters into a dental plan contract with a third party that will act as the plan administrator. Dental plan contracts are lengthy, complex documents that define what services are covered and under what circumstances those services are eligible for reimbursement.
Some limitations such as frequency limitations — for example, “This service is covered once every three years” — are easily understood, while others are more complex, such as, “This service is covered only when there is evidence of recurrent decay or fracture”. Dental plan administrators are contractually obligated to reimburse patients based upon the terms of the dental plan contract. This means that in some instances, necessary treatment may not be covered.
There are more than 30,000 dental plan contracts in Ontario, and each one is a little different from the next. As a smart consumer, you should make it your job to understand the details of your dental plan, and to supply your dental plan administrator with necessary information such as pre-treatment forms, claim forms or any supplementary information. You are also responsible for making arrangements for payment to your dentist for the dental care received.
The Dentist's Responsibilities
Your dentist, in accordance with the Regulated Health Professions Act and applicable regulations, will give you information on available treatment options appropriate to address your dental care needs, regardless of the nature and extent of your dental plan coverage. In addition, the dentist will assist you by supplying information required to enable you to receive benefits to which you may be entitled under your dental plan.
How Your Dentist Helps You With Your Dental Plan
Your dentist will be happy to supply you with claim and pre-treatment forms, which you will need to receive benefits through your dental plan.
Sometimes additional information may be requested by your plan administrator in order to ensure that the treatment is covered by your plan. In such cases the plan administrator will write to you and ask you to obtain the information from your dentist. Your dentist will supply any information you request, but it is your responsibility to provide it to your dental plan administrator. This ensures that your health record remains confidential and your privacy is protected.
Dental plans are designed to help patients pay for their dental treatment. However, not all dental treatments are eligible or fully reimbursable. If your dental treatment is only partially covered, you will have to share in the cost of your dental care.
Remember, you are a partner in your oral health. All treatment and care decisions should be made by you and your dentist based upon your actual needs, aside from your dental plan coverage. Your dental plan is not necessarily a treatment plan!
Dental Fees vs. Dental Plans
There may be a difference between the price your dentist may charge you and the amount covered by your dental plan. Here are three reasons why:
The amount your dentist may charge you and the amount your dental plan may reimburse you for might be different because these two prices are not derived in the same way.
When your employer and insurance carrier determine the amount of money your dental plan will pay for services covered under the plan, they take into account the specific circumstances of your company and its employees.
They consider such factors as company funds available for employee benefits, the nature and extent of use of the dental plan by the employees, and which version of the ODA Suggested Fee Guide for General Practitioners is used by the insurance carrier.
The ODA Fee Guide is a reference of suggested fees for dental services that is updated annually by the Ontario Dental Association. Some employers may use a current issue of the guide, while others may use past issues of the guide.
On the other hand, every dentist sets his or her own fees, considering the factors affecting both the practice and the patients served. The ODA Suggested Fee Guide helps dentists derive fees, but this is only a guide and the fees are only “suggested.”
A dentist may use this guide to formulate a fee for their dental services. Once a dentist has established a fee for a certain service, with special exceptions, he/she will charge that fee to all patients, regardless of whether or not the patient has a dental plan.
For some dental services, payment may be based on a cost-sharing arrangement between the employer and employee. In these cases, the patient pays for a portion of the cost, while the plan pays for the remainder.
As identified on the claim form you sign after you receive a service, you are responsible for the bill. This means you are also responsible to pay for the portion of the bill not covered by your plan — the portion known as the co-payment. It is illegal for the dentist to waive or ignore the co-payment and a dentist who does this could lose his or her licence.
If the problem requiring dental services is harder to resolve and requires more time or work by the dentist, the fee may be higher than the dentist's usual fee. Similarly, if the problem is less complicated and requires less time or work to resolve, the fee may be lower than what the dentist would normally charge.
In other cases, sometimes the fee will prevent a patient or group of patients from obtaining dental care when it is needed the most. For example, a toothache can result in oral infection if not treated on time. This can pose a great risk to patients who are in poor overall health, particularly those who suffer from heart disease.
In cases like this it is better to discuss the situation — including the fee — with the dentist. Often, a better solution can be found rather than having the patient forgo the necessary care. This should involve working out financial terms with the dentist and discussing all possible options.
Commercial Lab Charges Explained
There are many dental services that require additional “commercial laboratory procedures.” As your dentist can explain, dental procedures that involve the services of a commercial laboratory may include:
The fees charged for laboratory services are in addition to the dentist's professional fee for the service or treatment provided. In most cases, the laboratory services are performed by companies and not your dentist. Your dentist will arrange for a commercial laboratory to do the work to precise specifications that meet your treatment needs.
While the lab fee is passed on to patients, it is not the dentist's fee. The lab charges passed on to you by the dentist will be the exact amount that the laboratory has charged your dentist to provide the service.
When completing your claim form, the fee for the service performed by the dentist, such as a crown or bridge, will be listed as a professional fee. The laboratory charges reported on the form, using procedure code 99111, will be the fee charged by the commercial laboratory. Again, this is not the dentist's fee.
Laboratory charges must be completed in conjunction with other services. The amount payable by your dental plan will be limited to the reimbursement percentage of the services that required the lab work. This percentage is determined by the employer or plan sponsor and there are a variety of ways in which reimbursement is handled by the plan administrator.
To find out the level of reimbursement that can be expected from your dental plan, you should request that your dentist prepare an estimate of the professional services and the estimated laboratory charges, which should then be submitted to your plan administrator.
The predetermination of benefits you receive back from your plan administrator will explain how your benefits for these services are calculated so that you are aware of what your costs will be, before you receive the treatment.
Filling out a dental claim form can be a bit of a challenge. In most cases, help is available from your human resources department or the customer service contact at your benefit plan provider. However, what you may not be aware of is that there are laws governing how a claim form may be used by an employer or plan provider.
In this section we'll highlight some important things you should know, which will help you protect your privacy and security and that of any family members who are covered under your benefits.
Assignment of Benefits
The “assignment of benefits” is when a dental patient instructs an insurance carrier to make a payment of allowable benefits directly to the dentist. This has obvious appeal to a dental patient because the patient often does not have to pay the dentist up front, and then go through the process of filing a claim with their insurance carrier and wait to get reimbursed.
The ODA is opposed to assignment of benefits and actively encourages dental plan sponsors to make their dental plans “non-assignment” plans. Many people wonder why the ODA would oppose a process that many find convenient.
The answer lies in the fact that "non-assignment" dental plans can be less expensive than those that allow assignment, simply because the act of a patient paying for their dental care makes them financially involved in their oral health care. This provides very a good incentive for the patient to use their dental plan wisely.
Dental claim reimbursement is much faster than it was years ago, and patients are finding that when they pay the dentist directly their reimbursement cheque is received quickly; greatly minimizing the time they are out of pocket. It is not unusual to see the dentist on Monday and have the reimbursement cheque before the end of the week, thanks to electronic claims submission.
Also, many dentists accept credit cards, which typically have a monthly billing cycle. If complex treatment is necessary, dentists can arrange a payment schedule that allows a patient to budget for expenses and get reimbursement that is more conveniently timed.
Active decision-making about oral health care by patients and meaningful involvement in the financial matters of dental care, including the dental plan, is an important part of achieving excellent oral health care.
Many dental plans have co-payments, or in other words, a percentage of the claim amount that is not covered by the dental plan. These co-payments are usually 20 to 50 percent -- or more -- of the claim amount.
Many dental patients believe that the dentist can waive these amounts so the patient doesn't have to pay the money. This is not the case and the consequences to dentists for not making a reasonable attempt to collect the co-payment are very serious.
Patient Fact Sheet: "Waiving the Dental Plan Co-Payment"
Under the Dentistry Act, 1991 (Regulated Health Professions Act) dentists are required to make a reasonable attempt to collect the co-payment portion of dental fees for which the patient has payment responsibility.
The profession's regulatory body, the Royal College of Dental Surgeons of Ontario (RCDSO) is responsible for ensuring dentists adhere to this requirement.
In short, the dentist has a professional obligation to collect the co-payment. On some occasions, the dentist may run into difficulties doing so. On these occasions, the term "reasonable" should be noted, by taking into account the circumstances of the situation. This includes occasions when it is clear to the dentist that the patient cannot afford to pay the co-payment.
The dentist may then decide to cease pursuing the collection. The following options are open to make sure that the dental plan administrator is not misled:
1. Citing the reasons why this decision has been made, the dentist can advise the dental plan administrator of the situation and obtain his or her consent in writing to cease attempting to collect the co-payment and;
2. Also stating the reasons why, the dentist could advise the dental plan administrator that he or she does not intend to collect the co-payment, and that he or she will accept as full payment, the amount the plan administrator will pay under the plan.
In either of these scenarios, no attempts to mislead the dental plan administrator have been made. Intentional misrepresentation by the dentist can result in discipline by the RCDSO, loss or suspension of dental registration and criminal proceedings for insurance fraud.
Insurance companies also reserve the right to request that the patient provide proof that the co-payment has been paid. If the patient is unable to provide that proof, the insurance company may demand the patient make financial restitution to the insurance company or it may apply the overpayment to future claims.
Clearly, waiving the co-payment and misleading the plan administrator jeopardizes everyone involved — the dentist, the plan administrator and the plan sponsor.
"Please Pay Subscriber"
Printed in capital letters at the top right hand corner on the ODA Standard Dental Claim Form is a box stamped, "Please Pay Subscriber."
Although it may appear to be just a stamp on a form intended to conform to the rigor of a well-thought out administrative process, its history and meaning go far deeper. It is there to encourage the patient to be an active participant in his or her dental care, in a system where a plan sponsor and an insurance carrier is involved.
By not signing this box, the patient pays the dentist for the care received and then submits the completed claim form to the insurance carrier for reimbursement for the eligible benefit amount. The carrier then pays that amount directly to you, the plan member or subscriber.
Although the stamp has lost its place with the advent of electronic transmissions, the philosophy behind it remains. If the claim is electronically transmitted by the dental office to the carrier, then — unless otherwise agreed — the patient pays the dentist and the carrier will send the reimbursement to the plan member.
This process is called non-assignment. In other words, the subscriber did not assign his or her insurance benefits to the dentist, nor did the dentist accept assignment. This simple process has far-reaching benefits. The patient is aware of the cost of the dental service and will be more likely to:
The ODA has a long-standing philosophy encouraging non-assignment dental plans for the simple reason that when patients have a meaningful financial involvement in their dental care, better decisions are made.
Information About Using Claim Forms
In the early '90s, Bill C-18 amended a 1988 Income Tax ruling that specified that it is an offence for a person or employer to use an employee’s Social Insurance Numbers (SIN) for any purpose other than income tax reasons, unless authorized by the individual.
The modified provisions contained in C-18 extended liability to include consulting firms and insurance companies that use SIN numbers for group benefit administration. This meant that employers obtain either written permission to use SINs from each employee, including retirees, or they must devise a different numbering scheme.
The patient must provide his or her certification, SIN or identification number in Part 2 of the ODA Standard Dental Claim Form. Patients who are unsure of their identification number should refer to their employee benefits card or consult the Benefits Department at their place of employment.
The standard dental claim form conforms with the Personal Information Protection and electronic Documents Act (PIPEDA), a federal privacy law. The release on the claim form reads as follows:
I understand that the fees listed in this claim may not be covered by or may exceed my plan benefits. I understand that I am financially responsible to my dentist for the entire treatment. I acknowledge that the total fee of $ is accurate and has been charged to me for services rendered.
I authorize the release of information contained in this claim to my ensuring company/plan administrator. I also authorize the communication of information related to the coverage of services described in this form of the named dentist.
The Canadian Dental Association (CDA) is in the process of notifying dentists, dental plan administrators, printers and software vendors of this change. By January 1, 2007 dentists should be using the revised form.
The Canadian Dental Association is also amending the standard dental pre-treatment form to reflect the same wording change.
Dentists using CDAnet, will also be required to update each patient (parent/guardian) signature on file. For each patient participating in CDAnet the following wording must accompany the signature:
I authorize release, to my dental benefit plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.
The signature on file must be updated every three years.
The signature serves two purposes: it authorizes the dentist to submit the claim/estimate electronically and it authorizes the plan administrator to send the electronic explanation of benefits (EOB) or pre-determination of benefits (POB) or claim acknowledgement back to the dental office. Dentists are obligated to give the EOB, POB or claim acknowledgment to the patient prior to leaving the office.
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1. What will my dental plan administrator do with the information I submit?
Once your plan administrator has the necessary forms and any supplementary information requested, he or she will be able to determine your plan’s liability based upon the provisions set out in the contract.
You will be sent an explanation of how the benefit was calculated. All, some or none of your treatments may be covered or, for some services, coverage may be limited to an alternative, less expensive procedure. It is important to understand that necessary treatment and covered expenses are not the same things.
2. My reimbursement was limited or declined. Where do I turn for clarification?
First, read the explanation from your plan administrator carefully. In most cases, it will explain how the benefit was calculated and it will identify any limitations or exclusions that have been applied. Look for language such as “Under the terms of your dental plan...”, “Your plan limits coverage to...” and “These services are covered only when...”.
These types of statements indicate that there are limitations within your contract and they have been applied to your claim. As a result, some or all of the costs associated with your treatment will remain an out-of-pocket expense not reimbursable under your plan.
For more detailed information about the specific provisions of your plan, either consult your employee handbook, discuss the matter with your benefits department or speak directly to your plan administrator.
The Advisory Services Department of The Ontario Dental Association is also able to provide you with assistance and advice.
The Ontario Dental Association publishes The ODA Suggested Fee Guide for General Practitioners©. The Guide is based on the provision of dental services which are performed under normal conditions. It is intended to serve only as a reference for the general practitioner to enable development of a structure of fees which is fair and reasonable to the patient and to the practitioner. The Guide is not obligatory and each practitioner is expected to determine independently the fees which will be charged for the services performed, which means that fees will vary both above and below the Guide. The Guide is issued merely for professional information purposes, without any intention or expectation whatsoever that a practitioner will adopt the suggested fees.
The Guide is not available on the ODA website. However, copies have been placed in the reference section of many public libraries so that members of the public can access this document.
The Guide is approximately 80 pages in length, contains roughly 1,300 dental services and it is written using correct dental terminology so you will not find words such as cleaning, check-up, filling, cap, bridge and so on. Each dental service is identified by a five-digit number called a procedure code. The descriptions attached to the procedure code describe the dental service but not the reason the service was performed. For example, the Guide contains several procedure codes that describe veneers -- however, none of the descriptions identify the reason the veneer is being placed (i.e., for cosmetic reasons or to restore a tooth that is missing or has lost tooth structure). Furthermore, you will not find dental plan contract language such as basic, major, cosmetic nor will you find frequency limitations such as “once every six months”. This type of language is specific to a dental plan contract and it is used to describe the situations under which subscribers will be reimbursed for specific dental services. The Guide is a listing of dental services that general practitioners may perform.
If you have the procedure codes for the treatment that was prescribed or performed by your dentist, you may contact the ODA’s Practice Advisory Services staff who can provide you with information about the suggested fees.
Please call 416-922-4162, ext. 3301.