Maximum: Many insurance plans have a dollar maximum. The coverage period is either the policy year or the calendar year. The plan may specify a separate maximum for basic treatment and for major treatment (crown and bridge, dentures.) Often the maximum is combined.
Coverage Year: Coverage may be based on a policy year or on a calendar year.
Deductible: Some insurance plans have a deductible, which is a dollar amount which the insured must pay before the Insurance Company pays the claim. A deductible may be per individual or per family.
Fee Guide: There is no longer a standard fee guide in Alberta. Each Insurance Company sets its own fee guide and will pay claims as a percentage of that rate. Some Insurance Companies, such as Alberta Blue Cross, have several fee guides. Dental offices set their own fee guide and according to the Alberta Dental Association’s professional standards, may not vary that fee guide between patients or insurance plans. Thus, even when a plan states that it provides 100% coverage, the coverage rate may be based on the Insurance Company’s fee schedule and not that of the dental office.
Co-Insurance: The patient co-insurance is the percentage of the Insurance Company fee guide which is payable by the patient. If the coverage is at 100%, the patient is responsible for the difference in the fee guides, if any. If the coverage is at 80%, the patient pays the 20% as well as any fee guide difference.
Frequency Limitations: Your plan may limit the frequency of exams, tooth polishing, fluoride and x-rays.
Dental Cleaning Limitations: If you are advised to have dental cleanings in excess of the exam and polishing limitations, you are likely still covered for the very important scaling or rootplaning component of these appointments.
Scaling, the removal of subgingival plaque, is measured in 15 minute intervals. Typically Insurance plans provide for 8 to 12 units per calendar or policy year, and may be on a revolving basis. Generally, a cleaning appointment is 3 to 4 units of scaling (45 to 60 minutes), such that 12 units would allow for either 3 or 4 cleaning appointments per coverage year. Exams and polishes are thus scheduled in compliance with the Insurance terms, and not done at each cleaning appointment.