Some plans exclude certain procedures while others provide benefits for all dental services. Direct reimbursement programs reimburse patients a percentage of the dollar amount spent on dental care, regardless of treatment category. This method typically does not exclude coverage based on the type of treatment needed and allows patient to go to the dentist of their choice. These traditional programs usually pay a set percentage of the dentist's fee or the plan administrator's fee limit, whichever is less. This plan allows patients to go to the dentist of their choice.
Limits are the result of a contract between the plan purchaser and the third-party payer.
There is a wide fluctuation and lack of government regulation on how a plan determines the fee level. Deductibles and excluded procedures are common. These programs determine a list of covered services with an assigned dollar amount. That dollar amount represents just how must the plan will pay for those services. Most often, it does not represent the dentist's full charge for those services.