- practice daily preventive dental care,
- choose their dentist (GP & specialist),
- decide on their treatment plan based on the guidance of their professional,
- ensure they receive good value for the cost of the products and services they purchase,
- take responsibility for the cost and outcome of the dental services they choose to use.
- provide value for their clients,
- not provide products or services that are not necessary,
- not charge for products or services not provided.
- encourage daily preventive care,
- encourage early intervention,
- clearly communicate the extent to which they will reimburse the cost of dental services,
- protect against over-utilization which could undermine the viability of the plan,
- protect against over-billing.
Levels of Dental Coverage
Diagnostic and Preventive
Members and their eligible dependents should regularly visit the dentist so that disease can be detected and treated as early as is reasonably possible. With proper oral hygiene, it is reasonable for most people to see their dentist annually.
This level of service includes examinations, cleaning and X-rays.
If oral hygiene is not maintained, then scaling, fillings, extractions, periodontics (gum disease) and endodontics (root canal) may be required.
Years of poor oral hygiene and neglect can result in the need for crowns, inlays, bridges and dentures.
Braces are used to align irregular teeth. Most plans only cover dependents under the age of 19 for this benefit. Adult orthodontia coverage in uncommon.
Dental Benefit Schedule
Minor restorative, major restorative and orthodontic benefits often use coinsurance to reduce cost and share the responsibility of dental health.
Major restorative claims are often reimbursed at 50% - 80% up to an annual maximum of $1,500 - $3,000.
Orthodontic claims are often reimbursed at 50% up to a lifetime maximum of $1,500 - $3,000.
The Dental Association Suggested Fee Guide for General Practitioners in effect at the time of claim in the member's province of residence is normally used to determine the maximum eligible charge for each procedure. It is possible to use the Dental Association Suggested Fee Guide for Specialists. Some plan sponsors use the prior year's Fee Guide or a specific year's Fee Guide to adjudicate claims.