Dentures and Dental Plans
Many patients are fortunate enough to have dental plans. Most dental plans do include dentures as part of their coverage. However the way each plan administers these benefits can be very different. In general denture related services will fall into termed categories of A or B. Category A relates to relines, repairs, adjustments, consultations and in home visits. The B category relates to major services which would be replacement or provision of a new denture(s). It is common that the A category covers a higher percentage of the fee involved for service, but each plan is different.
When you are visiting a dental office it is wise to bring along your dental card as well as any other particulars that relate to your plan benefits. This will be of assistance when determining what your benefits will be prior to starting a service. It should also be noted that most plans can be direct billed, but there are exceptions.
The following is a summary of the more common dental plans we encounter and the general limitations on each.
MSA and CU & C
- Have now merged under the banner of Pacific Blue Cross
- Can be direct billed
- Generally authorizes new dentures every five years, relines every two years, and repairs as needed
- A category covers 60-100% of fee schedule
- B category covers 50-90% of fee schedule
DVA
- Can be direct billed
- Pays 100% of fee schedule for both A and B category
- New dentures every five years, relines every two years, and repairs as needed
- NIHB - Non Insured Health Benefits for First Nations
- Can be direct billed
- Does require preauthorization for work including relines and new dentures
- Limited to one repair a year
- Relines every two years
- New dentures every eight years
- Generally pays 95% of fee schedule in both A and B categories
MSSH - Ministry of Social Services and Housing
- Can be direct billed
- Dentures every five years
- Relines every two years
- Requires preauthorization which is a four to six week process
- Is intended to cover dental services at 100%, but because the Ministry fee schedule is below the standard fee guide, it is common to encounter balanced billing, where the patient is expected to pay the difference.
From here there is a host of less frequently seen plans which could include: Great West Life, London Life, Maritime Life, Mutual, Aetna, Laurentian Life, Sunlife and many others. Some of the smaller plans can not be direct billed and must be submitted through the employer for reimbursement. The percentage covered and limits of these plans can vary widely.
Remember it is always a good idea to determine the benefits of your particular dental plan prior to starting any new work. This will avoid any uncertainty of what portion you may be expected to pay.