Group Dental Insurance

Group dental insurance, also known as group dental benefits, is by far one of the most requested employee benefit plan options. Though most dental plans appear similar at first glance, they do vary depending on the insurer, plan design and plan type.

Group Dental Insurance

Group Dental Insurance Plan Design

An insurance broker that specializes in employee benefits will be able to work with you to find the group dental insurance plan that meets your need and budget. When it comes to meeting your needs in terms of coverage, one must design the plan appropriately and have access to the insurance carriers that are able to meet your requirements.

Covered Services

For group insurance purposes, dental services are generally grouped into three categories or tiers. The first category being basic or routine care, the second category being major restorative and the highest and final category being orthodontic services. It is important to note that accidental dental benefits are typically covered under your group insurance plan’s extended health care provisions.

Basic and Routine Care

  • Check-ups and complete dental exams
  • Fluoride, polishing and scaling
  • Dental x-rays, periapical films and panoramic film
  • Pit and fissure sealants
  • Minor restorations including fillings and prefab crowns
  • Oral surgery – removal of erupted or impacted teeth or residual roots, and associated anesthesia
  • Endodontic and periodontal procedures including, root canal therapeutics and gum treatments

Major Services

  • Crowns and onlays, dentures and bridges
  • Denture relining and rebasing, repair of dentures or bridgework

Orthodontic Services

  • Orthodontic exams, X-rays and casts
  • Braces and retainers for dependents under the age of 18 or 19 (depending on the plan)

Most small businesses with budget concerns will elect to take only basic and routine dental services. Businesses with a larger budget may consider electing major or orthodontic services.

Deductibles, Coinsurance and Fee Guides

Beyond the actual services covered, group dental insurance will include specifications around fee guides, coinsurance, deductibles, limits, maximums, replacement limitations, age limitations, and eligibility limitations.

Deductibles

A deductible, if used, is commonly expressed as a flat dollar amount per covered individual or per family, per calendar year. For example, $25.00 for a single person and $50.00 for a family or couple.

We tend to see businesses elect a small deductible such as $25.00 per single or $50.00 per couple/family annually, or no deducible for group dental insurance.

Coinsurance

Coinsurance is a form of cost sharing between an insurance company and the insured. Most commonly, 80 percent is paid by the insurer and 20 percent is owed by the insured after the deductible is met. Unlike deductibles, coinsurance can keep up with inflation and the cost of increased utilization because as dental expenses increase, so do the plan member’s contributions to the cost. Coinsurance levels typically vary by service, typically the coinsurance level will be higher for basic services (i.e. 80 percent) and lower for major services (i.e. 50%).

In our experience, most basic group dental insurance plans are set-up with either eighty percent coinsurance or one hundred percent coinsurance. If the plan is not fully pooled and the rates go up drastically, the employer may be forced to scale back from one hundred percent coinsurance to eighty percent coinsurance. For major services, coinsurance is typically fifty percent.

Fee Guides

A fee guide identifies a specific fee for a given dental procedure, following the fee guide in effect where the covered individual resides. Group dental insurance plans are typically set-up using the current fee guide, however, some plans may use an older fee guide. Using an older fee guide means the plan member will likely pay more out of pocket as the current dental fees are higher when compared to past fees. The majority of group dental insurance services are covered under the general practitioner’s fee guide.  Some plans may cover a specialist fee guide but not all will. It is important to note that dentists can follow the fee guide suggested by their dental association but there is no formal requirement for dental professionals to adopt or adhere to these fee guides.

Group Dental Insurance Limitations

Benefit maximums

A calendar year maximum will limit the amount paid for all dental services per covered individual in a calendar year. Maximums typically range from $750.00 to $2,000.00 and can be applied as a combined maximum for all services or separately for each category of services. Lifetime limits typically exist for services such as orthodontics. For instance, $2,500.00 per lifetime.

Where budget is of concern, one might set their plan up with a lower maximum and if a business has a larger budget for their employee benefits program they may look at a higher maximum.

Frequency limitations

Frequency limitations limit the number of services or units of service that are covered. For example, your plan may limit the frequency of your recall examinations to every nine months or twice per year. Another example is that your plan may limit the number of scaling units to 6 units per year, whereas another insurance carrier could cover the scaling at 12 units per year.

The majority of group dental insurance plans will have a six month recall as prevention is key in regard to dental care. Where budget is limited one could elect a nine month recall. Scaling units may be pre-set by the insurer, but in our experience a lower number of scaling units may not be sufficient for the plan member’s needs.

Replacement limitations

Due to the high cost of major services, group dental insurance plans impose limits to ensure a reasonable period of time on the replacement of specific prosthodontics. For example, crowns may not be replaced unless they are at least five years old, among other requirements.

Age limitations

With respect to group dental insurance, an example of an age limitation is that topical application of fluoride and pit and fissure sealants may be limited to dependent children under the age of 19.

Other Plan Provisions

Predetermination of Benefits

Dental plans will include a predetermination of benefits provision that applies to procedures expected to cost more than a pre-determined amount, such as $500.00.

Alternative Benefit Provision

This provision covers expenses up to the usual and customary charge for the least expensive treatment option that will produce a professionally adequate result. The insured does not have to opt for the proposed treatment option. However, if the insured and the dentist choose the more expensive treatment, the insured person is responsible for the additional charges beyond those allowed under the alternative benefit provision.

Continuation of Coverage

Group dental insurance contracts may allow for continuation of coverage in the event that coverage is terminated for any reason other than termination of the dental plan. This means the plan may pay for services where the course of treatment was started before coverage was terminated and the procedure and final billing are completed within a specified time (i.e. 30 days) after coverage has ceased. If continuation of coverage is offered at all, it is not typically extended to basic services.

Survivor Benefits

Typically, group insurance contracts will allow for continuation of dental benefits to the dependents of a plan member after his or her death. Most commonly, for twelve or twenty-four months. Coverage is extended without premium payment. Specific contract provisions will stipulate causes of termination outside of the set time period.

Group Dental Insurance Taxation

Dental premiums paid by the plan sponsor (i.e. employer) are tax deductible. If the plan sponsor pays less than 100 percent of the premium, they can only write off the portion that they are paying for. The premium and benefits are not taxable to the plan member (i.e. employee).

Exclusions

Many of the limitations and exclusions found in extended health care plans are contained in group dental insurance plans. Items and services that are not typically covered in a group dental insurance plan may include:

  • Cosmetic services or supplies unless required due to an accident occurring while covered under the plan
  • Protective sports appliances
  • Supplies or services related to an accident (accidental dental is covered under an extended health care plan)
  • Anything related to self-inflicted injury, voluntary participation in war, insurrection or riot, or resulting from a criminal act
  • Experimental treatments
  • Replacement of lost or stolen appliances or devices
  • Some services related to treatment that began prior to the effective date of coverage
  • Anything where no charge would have been levied in the absence of coverage
  • Anything covered by a government-sponsored benefits program (i.e., Worker’s Compensation)
  • Items such as travel, counselling, communication costs, missed appointment or form completion fees
  • Personalization or characterization of dentures
  • Full mouth reconstruction or vertical dimension correction
  • Any services or supplies not provided by a legally qualified dentist or denturist, acting within the scope of their licenses. Exceptions apply relating to service or supplies furnished by a dental hygienist
  • Third party ordered dental exams

Claims Processing

Similar to health care claims, a proof of loss must be provided to the insurer within twelve months after the date the expense was incurred and within three months (typically) after the date on which coverage has terminated for a plan member.

Given technological advances today, almost every dentist can submit claim information electronically to the insurer, at the point of service. The insurer would then transmit back to the provider to verify coverage under the plan. It is always wise to ask your dentist to verify what will and will not be covered before proceeding with any service. A verbal answer regarding covered services may be given to a plan member by a dental office without checking and, unfortunately, if the information is incorrect, the individual will be stuck paying the entire bill themselves.

Today plan members can also submit almost all claims online or through a mobile phone app themselves. If a paper claim is necessary, submission of standard paper forms approved by the Canadian or provincial/territorial dentals association are to be used.

Once a claim has been deemed eligible through any means, the insurer will calculate the amount to be paid to the plan member or provider, if an assignment of benefits was made. The insurer will then send payment to the plan member or provider (if applicable) along with an explanation of benefits. The explanation of benefits will outline what was paid, was not paid and why. If you are ever in doubt, a good insurance broker can explain why a claim payment was not paid and if warranted can help you get a claim paid that should have been paid when it was not.

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