How the Dental Fee Guide Impacts Your Employee Benefits Plan
By Sarah Mitchell
March 2, 2022
It's no secret that dental care is not always affordable. If you're lucky enough to have dental coverage included in a company-sponsored employee benefits plan, you might be surprised when you still end up having to pay out of pocket for treatment. The dental fee guide of your respective province could be to blame.
What exactly is a dental fee guide? In this blog, we'll break it down for you.
The Dental Fee Guide Explained
Each Canadian province and territory has a dental association that is responsible for publishing an annual dental fee guide. This guide contains all available dental treatments and an associated fee that dentists can consider when setting the prices at their respective clinics. It is critical to note that the fees published are suggestions only and dentists are not required to follow them when deciding on their prices.
You may be wondering, why wouldn't a dentist just take the dental association's fee suggestion?
The actual prices a clinic sets can vary for many reasons, including:
the complexity of a treatment
the time it takes to perform a treatment
the cost of products and materials used in a treatment
the use of specialized equipment
sterilization and safety protocols
hiring trained and licensed staff
ongoing continuing education for the dental staff
Knowing that pricing can vary, one key cost-saving strategy is to ask for a pricing breakdown from the dentist prior to receiving your treatment. This way you will have a better idea of what to expect and can shop around to other clinics if the pricing ends up being higher than you anticipated.
Quick Tip: Requesting a pre-determination (or to put it simply - a quote) is common practice for major dental work to be pre-approved by the insurer before treatment starts; however, it's ok to ask your dentist for an estimate before routine treatment too to avoid any financial surprises.
Now that we have a better understanding of what the dental fee guide is, let's look into why it matters to your benefits plan.
How the Dental Fee Guide Impacts Employee Health Benefits
Though the dental fee guides are suggestions for dentists, insurers use the fees outlined to determine how much a member will be covered for based on the treatment. To get a better understanding of how this works, we will walk through an example with a patient named Michael who lives in British Columbia.
Michael knows he has 80% dental routine care reimbursement included in his employee benefits plan.
He becomes a new patient at a dentist in Kelowna, BC, and wants to get a new patient examination done.
The BC Dental Association has released the 2022 General Practitioner's Fee Guide with a suggested fee of $60.60 for the new patient examination that Michael would like to have done.
Michael, who is unaware that the BC dental fee guide exists, gets an invoice for $80.00 after his appointment.
He submits a claim for $80.00 through his employee benefits plan expecting to be reimbursed for 80% of that $80.00 (0.8 * 80 = $64.00).
To his surprise, Michael is only reimbursed for $48.48 and has to pay the remaining $31.52 out of pocket.
So what happened?
The insurer of Michael's benefits plan used the 2022 General Practitioner's Fee Guide to establish a reasonable and customary limit (aka the highest amount they will cover) for a new patient limited examination.
Since the fee for this service was listed at $60.60 in the guide, the insurer of Michael's plan covered 80% of $60.60 which is $48.48.
That left a balance of $80.00 - $48.48 = $31.52 for Michael to pay out of pocket.
Each province and territory has a dental association that sets fees for services and treatments, but the dentists are not legally required to follow these fees when setting their prices. If you are hoping to avoid a surprising out of pocket expense following a trip to the dentist, here are some steps you can take:
Request a Cost Breakdown: Ask your dentist for a detailed breakdown of costs before you receive your treatment.
Consult Fee Guide: Look up the dental fee guide for your respective province or territory on the dental association's website (see list below). These guides are technical so they are not always available to the public. Some associations publish an abbreviated version online, while others may direct you to a public library for a print copy.
Contact Your Insurer: Call and ask your insurer what the cost is as outlined in the fee guide for the treatment you will be receiving so you can compare it to the price the dentist provides.
If your plan is with Simply Benefits and you have questions about your coverage, please contact our Support Team; otherwise, please speak with your employer's Plan Administrator or Benefits Advisor.
Dental Associations by Province
As stated above, dental guides are technical and created for dental professionals so they are not always available to the public. However, some associations publish an abbreviated version online, while others may direct you to a public library for a print copy.
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