Dental benefits are typically separate from EHC and are subject to a fee schedule, which is a schedule of fees that the insurer considers reasonable for each procedure. The dental benefit pays a percentage of the fee schedule, and the difference (between what the dentist charges and what the schedule allows) is the patient's responsibility.
The three tiers of dental coverage:
Basic services (Preventive and diagnostic): examinations, x-rays, scaling, polishing. Most plans cover basic services at 80 to 100 percent of the fee schedule after a deductible.
Basic restorative services: fillings (usually amalgam as standard; composite may be covered to the amalgam fee), simple extractions, and other restorations. Coverage is commonly 80 percent.
Major restorative and orthodontic services: crowns, bridges, dentures, implants, and orthodontics (braces). Coverage for major restorative is commonly 50 percent, with lifetime maximums. Orthodontics, if covered, typically has a lifetime maximum (e.g., $2,000 per patient) and covers dependents under a specified age.
Frequency limits: plans specify how often certain procedures are covered. An examination may be covered once per calendar year; a set of x-rays may be covered once every 24 months; scaling may be covered twice per year.
Exam trap: questions may describe a client who wants a crown when the dentist says a filling would be clinically adequate. A plan provision requiring treatment at "the most economical clinically adequate level" would pay only to the filling level. The client pays the difference for upgrading to the crown.