Many Albertans have a dental benefit plan through their employers. Although many people refer to these plans as “dental insurance”, they are actually not insurances but rather a prepaid dental plan. There are many different types of plans, each one with a policy a little different from the next. For this reason, it is important that you understand the details of your dental plan (ie. what procedures and services are covered and are there frequency limitations, etc).
At District Family Dental, we are pleased to offer direct billing to most insurance companies for your convenience. Our dedicated team will be happy to help you understand what your plan covers, and can submit a pre-determination form to your plan so you will know what your plan covers before any treatment is initiated. It is important to note that not all dental treatments are eligible or fully reimbursable. Any discrepancy in fees charged, after reimbursement by the insurance company, will be your sole responsibility.
For your convenience, we accept several payment options:
- Credit Card: Visa & MasterCard
- Interac Direct Payment
- Direct Billing (also known as Assignment of Benefits)
Frequently Asked Questions About Dental Benefits
Please click the question to reveal the answer.
Q - What does a basic plan cover?
Most dental plans cover only a specific percentage of the cost of eligible dental treatment services (services covered by the plan); you are responsible for the remainder along with any costs not covered by the plan.
For example, many standard dental plans will cover 80% of basic/preventive dental services (ie. dental exams, X-rays, cleanings, fillings and root canal therapy) while coverage for other procedures (ie. crowns, bridges, veneers and dentures) may be at 50%. Other plans may cover a higher or lower percentage of services; it is rare for any plan to cover 100% of every service as most dental plans have a financial limit. See also: What is the dental plan co-payment?
Q - What is the dental plan co-payment? How much do I have to pay?
The co-payment is the patient’s portion of the cost of care. Dental plans are an employee benefit designed to offset the cost of dental care. Generally a dental plan will only cover a portion of the cost of any treatment service – the patient is responsible for any costs not covered by the plan (the co-payment).
District Family Dental has a legal and regulatory requirement to collect the co-payment from all patients.
How much do I have to pay?
This will depend on your plan coverage. Many plans will cover a percentage of costs for eligible services. For example, a plan may cover 80% of the cost of basic/preventive services (ie. examinations, fillings, and cleanings). This percentage is based on the costs outlined by the plan provider and may vary from the actual costs of the treatment. Major procedures (ie. crowns, bridges, and dentures) may be covered at 50% of the cost outlined by the plan. You are responsible for any costs not covered by the plan.
Q - Why doesn’t my dentist/ dental office know what my plan covers?
There are many dental plan options available. Plan coverage is determined by you and/or your employer. The details of your plan are protected by the Personal Information Protection ACT (PIPA). While the team at District Family Dental can help you understand your plan, we do not know the details of your plan and/or any changes that may occur.
It is your responsibility to understand your plan covers and be aware of any financial limits and changes to your plan. See also: How can I find out what my dental plan covers?
Q - How can I find out what my dental plan covers? How can I change my dental plan?
The details of your plan are protected by the Personal Information Protection Act (PIPA). While the team at District Family Dental can help you understand your plan, we do not know the details of your plan and/or any changes that may occur.
Employer plan: If your dental plan is part of an employee benefits package, ask your employer and/or human resource manager for a copy of the plan booklet. You should also speak to them about any questions related to your plan and/or recommendations you may have.
Individual plan: If you have and/or are purchasing a private dental plan, ask the dental plan provider about available plans outlining what they will cover and for what you will be responsible. When choosing a plan, look carefully at what you will be required to pay and what treatment will be covered. Ask your dental plan provider for a copy of the plan booklet.
Many plans also post information online. Ensure that you have the correct information to be able to access these details. Also ensure that you are aware if any changes to your plan occur prior to any dental appointments and/or treatment.
Q - How do dental plan carriers determine coverage?
Many dental plan carriers use the Alberta Dental Association & College (ADA&C) suggested fee guide as a reference to determine plan coverage. They choose treatment services and base the percentage of plan coverage on the fee outlined in the guide. They do not always use the most current guides; in some cases, coverage is based on fees outlined in a previous year’s guide (going back a year or more). In addition, dental plan fee schedules may not include all the codes in the current ADA&C guide. See also: What is the suggested fee guide?
Note: Professional dental organizations and dentists are not involved in any aspect of determining dental plan coverage.
Q - What is the suggested fee guide? Does your clinic follow it?
The Alberta Dental Association (ADA&C) produces an annual suggested fee guide for dentists in Alberta. This document outlines over 1,600 dental codes and code descriptors related to specific elements of dental treatment.
District Family Dental follows the ADA&C 2019 fee guide.
Q - Why does my dental plan only cover a section of treatment?
Dental plans are developed to offset some of the costs of treatment and generally include a selection of coverage; they are not developed based on your unique dental care needs, nor do they cover the full range of dental treatment services available.
Dental plans are selected by the plan purchaser, usually as part of a group benefits plan. Many plans will cover a range of diagnostic (examination) and preventive services (scaling, polishing). Such services are common to all patients and aid in the prevention of dental disease. These plans may also have limits on the amount or frequency of services and treatment which is not based on what any individual may actually need. Additional treatment services will vary, as will the percentage of coverage patients receive for treatments covered by the plan.
Q - Why can’t my dentist create a treatment plan based on my dental plan coverage?
As health care providers, our first obligation is to your health. If you have an issue with your mouth, we will present treatment options to meet your oral and overall health needs; your treatment plan is not based on your dental plan coverage.
It is important to make your treatment decisions based on your health care needs, not based on what your dental plan covers. Our team can help you get a pre-determination for treatment to understand what costs may be covered by your dental plan. See also: What is a pre-determination?
Q - What is a pre-determination?
A pre-determination is an estimate of what treatment your dental plan will cover and what you will be responsible for. Our team will submit an outline of the proposed treatment to your dental plan provider prior to proceeding with treatment. It is an estimate only and does not guarantee the final costs you will be responsible for paying.
It is important for you to be well-informed on your plan coverage. Check with your dental plan provider to clarify when a pre-determination is required. Some plans may only reimburse some services if a pre-determination is received in advance of treatment. Also be aware that pre-determinations may be valid for a limited time; what is covered can change if your reach the financial limits of your plan; and/or other changes can occur to your plan before treatment is completed.
The final treatment coverage is determined by your dental plan carrier. Any costs not covered are your responsibility.
Q - I have 100% coverage for dental check-ups and cleanings, but I still end up with out-of-pocket expenses. Why?
If your plan states that you have 100% dental coverage, your plan will pay 100% of the treatment procedure according to the fee guide set by that dental plan provider. A discrepancy arises when the fee charged as suggested by the fee guide from Alberta Dental Association & College (ADA&C) exceeds the fee guide amount set by the dental plan provider.
Q - What is dual coverage?
Dual coverage is when you are covered by two separate dental plans, such as your own plan and a spouse’s or a partner’s. It is likely that one plan provides the primary coverage while the second provides some additional support. This does not mean that you will always have 100% coverage. Dental plans generally cover a percentage of treatment and the patient is responsible for the remaining portion – the co-payment. This is particularly true if both you and your spouse/ partner are covered by the same plan.