Dental benefits that are provided through the employer and under a group insurance program, are usually reimbursed according to the Ontario Dental Association's (ODA) suggested fee guide for general practitioners. Some dental benefit plans may have a lag in the year of the ODA Fee Guide on which they will pay. For instance, if the year is 2018, and a plan has a 1 year lag, dental expenses will be paid based on the ODA Fee Guide that was in effect for 2017. You will be responsible for the difference.
Coverage for dental services can vary greatly from plan to plan. Dental benefit services can generally be broken down into three different categories:
While every plan is different, basic services are usually reimbursed at a higher rate than major services or orthodontics. A typical plan will cover anywhere from 75-100% of costs for Basic Services.
Examples of Basic Services:
- Oral examinations such as initial, recall and emergency exams
- X-rays, fillings, polishing/cleaning and topical fluoride treatment (fluoride is sometimes limited to children)
- Diagnostic testing
- Retentive pins
- Extraction of teeth
- Endodontics, periodontics and oral surgery
While every plan is different (not all plans cover major services), Major Services are usually covered at a lower rate than Basic Services. If a plan covers Major Services, it will typically reimburse anywhere from 50-75% of Major Services costs.
Examples of Major Services:
- Dentures, partial dentures, complete dentures, lab fees and repairs
- Bridges and repairs to bridges
- Crowns and repairs to crowns
- Inlays and onlays
- Pins in inlays, onlays and crowns
- Post and core
Some dental plans do not cover orthodontics. When a dental plan does provide for orthodontic coverage, it is often for children up to the age of 18 (sometimes longer but rarely for adults), and reimbursement can range 40-75%. This benefit will usually have its own yearly or lifetime maximum that is separate and apart from Basic and/or Major Services.
Examples of Orthodontic Services:
- Diagnostic services, orthodontic cast, observation & adjustment, repairs, alterations, re-cementations
- Fixed bilateral/unilateral or removable orthodontic appliances
- Appliances to control oral habits
Be Sure of What the Dental Plan will Pay – Get a Predetermination!
Before you undertake any significant dental work it is highly advisable to seek a predetermination. A predetermination is a way of getting a commitment from the insurance company of what they will pay, before you get the work done.
You can ask your dentist to request a predetermination before any major dental work. They will send a treatment plan to the insurance company. The insurance company will then assess the proposed course of dental treatment and provide an estimate of what will be reimbursed under the dental plan.
By submitting a predetermination you can avoid any unpleasant surprises with respect to your dental coverage and be assured of payment.
Most insurance companies allow for direct electronic payment to your dentist, so that you need only pay the outstanding amount.
What to do if you are denied a dental benefit by the Insurance Company?
Reasons for a denial will be outlined in the predetermination or explanation of benefits from the insurer and can include:
- Insufficient documentation was submitted
- There is no coverage under your plan for the type of benefit you are requesting
- You have already reached your maximum allowed – yearly or lifetime
You should call the dental insurer and inquire why you were denied and if there is any additional information you could submit that would allow the claim. Keep copies of all paperwork you submit and receive from your dental insurer. You may need this documentation later on if there is a dispute.
If the insurer maintains the denial and no further documentation will assist, then contact your employer and/or local union representative to confirm your coverage, and if the claim was correctly denied.
OPSEU does not represent members in appeals for dental benefits unless there is a formal Joint Insurance Committee in place through your Collective Agreement. You may have the option to grieve denial of your extended health care benefits. You should refer to your collective agreement and/or contact your local representative to confirm.
If you wish to contact the Pensions and Benefits unit, please email us at email@example.com.
This publication contains general information and is intended as a reference only. It is not intended as a substitute for independent legal advice regarding your particular situation.