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Most of the time the Provisions highlighted above are overlooked and/or misunderstood since written into the Dental Insurance Plans, in fine print, at the bottom, or referenced with an asterisk and all throughout the Section Titled: "Covered Benefits" many, if not all, of the time frequency, limititations, waiting periods and exclusions are not listed under the Section Titled: "Plan Exclusions and Limitations." Similar to Pre-Existing Conditions and Waiting Periods or in reality Permanent Exclusion Riders placed on a policy, members unexpectedly, mostly after Dental Procedures are completed, are informed there is No Coverage or Benefits and the insured member is responsible for paying the entire Dental Bill. For example, if you are missing a tooth, prior to joining the Dental Insurance, and would like to get a fixed bridge, will the Dental Insurance Plan pay or ever pay in the future for the initial placement of the bridgework?  Most Voluntary Indemnity Dental Insurance Plans will not pay and have a Provision that requires, the tooth must be lost while covered under the Plan, similar to a Permanent Exclusion Rider. In other words, if you did not lose your tooth while a covered member of their Dental Insurance Plan, they will never pay any benefit toward the replacement or repair, not now or any time in the future. Other Dental Insurance Plans require you must lose at least one Related Tooth and the tooth was not an abutment to a prosthetic appliance. An abutment would be the tooth that a fixed bridge is attached to or the crown on either side of a fixed bridge. The abutment is the most likely tooth to go bad since it is already crowned and used for the support of a bridge or is pressured from supporting a partial over the years. Almost like an incentive to have a good healthy Related Tooth removed or crowned to be able to qualify for the benefit to pay for the one that was missing or weakened before joining the Dental Plan. 

The NALC Gold and Silver Dental Insurance Plan Options cover dental work that was Placed Prior to your Effective Date starting on the First Day of Coverage. If an Insured member were to lose a natural tooth after becoming covered under the NALC Smile, Federal Employee Dental Plan, it of course would be covered from the effective date. If the tooth lost is related to or adjacent to a Tooth Missing Prior to the Effective Date, or the lost tooth is an abutment to an existing dental appliance, then BOTH TEETH are Covered. In addition, the Replacement of existing dentures or fixed bridgework that cannot be repaired and the replacement of existing inlay, onlay or crowns Placed Before the Effective Date of coverage are also covered, provided it has been 5 years from the date they were initially placed or last replaced  starting on the Effective Date of the Smile Dental Policy. The 5 year limitation is even waived if the insured were to loose a natural tooth while covered under the plan. Unique among Dental Plans, after being insured under the Smile Dental Plan for 36 months, the Gold and Silver NALC Smile, Federal Employee Dental Insurance Plans will pay for any Teeth Missing Prior to the Effective Date. The Benefits for Teeth Missing Prior to the Effective Date become available due to a limitation listed under, Major (class C) Covered Prosthetic Services, addressing coverage for lost teeth while covered under the Plan, that no longer applies after being insured under the Plan for 36 months. These Benefits alone separate the NALC Smile, Federal Employee Dental Insurance Plan from the competition and is why many Dentist refer to this Dental Insurance Plan as the "Cadillac" of Dental Plans. Members are rewarded with Increased Benefits for their continuation of coverage. Most Dental Plans will Never pay any benefits for teeth missing prior to the effective date or pay benefits for dental work and/or prosthetic appliances placed before the policy effective date. Benefits for Major (class C) services in the first twelve months of coverage are 10% Increasing to 25% at the end of 12 months, then Increasing again to 50% at the end of 24 months may seem minimal at first, but the Plan provides coverage from the Effective Date and has No Waiting Periods. Enroll in the NALC Smile Federal Employee Dental Plan, and participate in a Dental Plan that provides First Day Coverage for your Existing Dental Work done in the past and provides benefits for any lost or missing teeth prior to the Plan Effective Date. A Dental Plan without a lot of red tape or hidden exclusions. A Dental Plan worth keeping in the future with Increasing Benefits that make sense. Whats more, a Dental Plan that allows you to Keep Your Dentist.

Time Limit Frequencies on Procedures and/or Waiting Periods before the insured can Replace any existing Dental Work done in the past, if covered under the policy are necessary to know and compare, since dental work and dental appliances don't last forever and periodontal services could be required more often then the Plans Time Limit Frequencies allow. Again, listed under or part of the "Covered Benefits Section" and not addressed under "Dental Plan Exclusions and Limitations," there are Waiting Periods insureds must satisfy before Dental Insurance benefits are available for replacement of Dental procedures done in the past. Additionally, the Frequency of a Benefit is an important factor. Some Dental Insurance Plans will refuse to pay benefits for a second teeth cleaning if six months, and not a day less, have passed since the last cleaning appointment. This is a timed frequency benefit and it can become difficult to properly schedule a families cleaning appointments. Concerning replacement, when Dental services fail prematurely, most of the time, we refuse to go back to the Dentist that preformed the services, and filing formal complaints against the Dentist is never a pleasant situation. Finding and Keeping a Quality Dentist will save teeth and thousands of dollars by avoiding the need to have bargain cut rate, inferior quality and/or less expensive "alternate treatment" Dental procedures done over again.

The Voluntary NALC Smile, Federal Employee Dental Insurance Plan allows you to select Any Dentist or Specialist and pays the stated Benefits and does not attempt to pay your Dentist a reduced or discounted fee. The NALC Smile, Federal Employee Dental Plans Claim Payments are not subject to being priced by a PPO Networks reduced negotiated fees, nor are they based on a bias percentile table, short of what actually are reasonable and customary charges. Take a Front Seat in the Dental Office of your choice, The NALC Smile, Federal Employees Dental Insurance Plans True Indemnity Claim Reimbursement is Fee for Service and is based upon the current normal fee charged by the Dentists in the area zip code you seek Dental Services. To date we have not had one complaint from a member the reimbursement for services was short and not within reasonable and customary or the fee charged by the Dentist. No List of Provider Dentist to worry about or verify who is still participating and you are never penalized for being "Out of Network" with a reduction in benefits and get balance billed the difference in the Allowable PPO Network Fee, Company Defined Allowable Fee, Slanted Percentile Table or have No Coverage at all.

Most of us know or have an idea of what are Dental needs are. Cleaning twice per year per person are built into Dental Plans premium cost, so it is assumed all members will seek a cleaning twice per year per person. In addition to the Smile Gold and Silver Dental Plans the Smile Dental Plan offers you a Bronze Plan that covers Preventive and Basic Services Only and No Major Services at a very affordable monthly premium. The Bronze Plan works well for individuals or families that don't foresee the need for Major Dental work other then possibly x-rays, fillings or oral surgery which are all covered under Basic Services. Ask yourself these questions, which will better enable you to make the right choice of a Voluntary Dental Insurance Plan that will serve your families current and future Dental Health needs.

Do you have a Dentist, or would you prefer to go to, or back to a particular Dentist?

Have you checked the background of your Dentist or the Dentist you would select from a PPO Network with an Internet Dentist Background Checker, your local State Dental Association or Public Court Records?

If considering a PPO Network or Dental HMO, do the PPO Networks or Dental HMO's have enough participating Providers and Specialists to treat and service the members enrolled? Call and check the available appointment times and are they within a reasonable time frame? Can each member in your family get an appointment, twice per year, to have their teeth cleaned and be able to maintain Good Dental Health by utilizing the already paid for teeth cleaning benefits?

If considering a PPO Network or Dental HMO are the Dentist in your area reluctant to participate as a provider due to the compensation agreements offered by the PPO Network or Dental Insurance Plan? What is the procedure and how difficult is it to see a Dental Specialists? How many specialists are on the list and what are the benefits if my child(ren) seek services from a Pedodontist? Are there enough Endodontist?

Does anyone proposed for coverage need dental work, other then Preventive, Now and would the dental work be covered?

Is any family member missing any teeth, and considering bridgework to replace the missing tooth? Will the Dental Insurance pay any benefits for teeth missing or lost prior to being covered?

Does any family member need or foresee the need to have Previously Performed Dental Services repaired or replaced? How old must the Previous Dental Work be before it would be considered eligible for repair or replacement? Can you get the Dental Records if requested to prove how old it is?

Is my current dental work over 10 or 15 years old and getting to the point of possible replacement? If so, how long do I need to be covered before I can have it replaced and will the dental plan I select provide benefits without having to lose teeth while covered under the Plan?

Will the Dental Insurance Plan pay benefits toward the cost of General Anesthesia including Intravenous Sedation, for oral surgery or is it a limited benefit?

Does anyone need Periodontic (gums) Surgery or Continued Maintenance  and will the cleanings, scaling and root plannings be covered, what is the time frequency of the periodontic benefit?

Do I want to be Locked In to one Dental Insurance Plan for approximately four years for a Child Only Orthodontic Benefit? Due to a 2 year waiting period and thereafter pays 50%, as billed for services, which will take approximately two more years to pay out the lifetime maximum benefit. Will I want to afford to pay the future increases in premium and not change Dental Plans? Are there any take-over provisions toward the orthodontic waiting period if I change to another Dental Plan during Open Season? Will I receive credit for the time I was covered on my old Dental Plan, toward the waiting period in the new Dental Plan if I change Dental Plans?

Can you postpone or get some type of alternate treatment for a currently needed Dental procedure not covered for the time necessary for it to become covered under the Dental Insurance Plan?

Are you and your dependants in Good Dental Health and only concerned about semi annual cleanings or possibly fillings, x-rays or oral surgery and don't have any Major Dental problems, or foresee Major problems and don't want to pay the increased premium rates for a Dental Plan that includes Major (class C) services and Orthdontic (class D) services?

Do you want a Dental Plan that includes an Orthodontic (class D) benefit that after two years will most likely increase premium rates as the insured members qualify for the orthodontic benefit, even if you are not using the benefit?

Would a Dental HMO better suit your dental needs because there is no annual maximum benefit and you or your family need a lot of dental work that would far exceed the Indemnity Plan annual maximums?

Policyholders and Dental Offices having to submit supplemental written reports including evidence to justify a recommended treatment plan, in addition to a Predetermination Claim Forms and Standard Claim Forms can quickly become annoyed. Dental treatment is postponed or the Policyholder and Dental Office become impatient with the delay of pending claim payments, which could be denied, paid as Alternate Treatment resulting in partial payment or remain pending for incomplete documentation. Predetermination of Benefits should be submitted BEFORE treatment is STARTED if the proposed treatment exceeds $300 to $500. Pretreatment review is Rarely Required, but is often requested by Dental Insurance Plans. If Pretreatment review is NOT Submitted it puts the insured in a position to receive a minimum benefit or the "Alternate Treatment" benefits. So submitting a Predetermination or pretreatment review BEFORE any dental treatment is performed is HIGHLY Recommended. ALWAYS submit Pretreatment review for your own benefit and you will know more about where you stand. Approval of a Predetermination Claim does not guarantee payment of claims but should surface obvious Non Covered services and provide the insured an estimate of their out of pocket cost. A Predetermination notifies an insured of any additional documents or records that may be required before the treatment plan can be approved. Submitting a Predetermination can alert the insured that the Dental Insurance Company will only approve  "Alternate Treatment" benefits or the less expensive course of treatment. This means the Dental Plan has determined that the restorative need to the rendered service was not established and the benefits are reduced. An example would be allowing benefits for a filling and not a crown. This can be a major difference in benefits and the insureds out of pocket expense.

The NALC Voluntary Federal Employee Dental Plans request that a predetermination form be submitted if the course of treatment is to exceed $300. There is no contractual Penalty to the insured for not submitting pretreatment review but the Dental Plan, has the option and can pay for the least expensive method of treatment regardless of the method used. It is HIGHLY recommended that the insured member submit pretreatment review to be able to get the maximum benefits in addition to the reasons outlined above. The Dentist treatment plan consisting of a description of the planned treatment with estimated charges and diagnostic x-rays would be required. The insured is Not required to submit written supplemental reports or justification summaries this would be unusual and something an insured might do if involved in a claims appeal. The average time for claims turn around with the NALC Dental Plan is 15 to 30 business days. Preventative (class A) claims are generally within 15 business days. As a part of the General Provisions contained in the Security Life Dental Plan Certificate it states under Time Payment of Claims " We will pay immediately, or within 30 days following receipt of due written proof of loss, all benefits under the policy. If we fail to pay your claim within 30 days of Our receipt of due written proof of loss, We will pay interest at a rate of 9% per annum. Interest will be paid from the 30th day after Our receipt of due written proof of lose to the date We pay the claim."

Defining the definition of a Reasonable and Customary Fee is somewhat like defining the Retail Price of Diamond Jewelry or Furniture. Reasonable and Customary Fee is referred to in most Dental and Medical Insurance contracts as the R&C Fee, or can be referred to as the UCR Fee meaning the Usual, Customary and Reasonable Fee. Other terminology utilized is The Average Charged Fee or The Most Common Fee Charged in the Geographic Area where the Charge is Incurred. Insurance Company actuaries need to know what the average cost of dental or medical services will be, to calculate what they think will be the correct factors or premium rates for a given policy. One of the most common ways to get the Reasonable and Customary Fees is through the Health Insurance Association of America (HIAA) now called the America's Health Insurance Plans (AHIP) which represents nearly 1,300 Insurance Companies that provide coverage to more then 200 million Americans. Some policies will state that the Reasonable and Customary Fee is based on the average HIAA fee and the R&C is adjusted upward or downward each month and reported to the claims division. Another method is for Dental Insurance Companies to calculate a Reasonable and Customary Fee as a percentile (e.g. 90th percentile table) of fees reported on claims. The calculation of the R&C maximum fee is based upon carrier-defined geographic areas and carrier-defined time periods.

An important point to make is that the Reasonable and Customary Fee or UCR Fee is NOT the same as an Allowable Fee, Scheduled Fee, Negotiated Fee, Network Allowance, Plan Allowance, Maximum Allowable Charge, or Network Allowable Fee. These acronyms refer to either an Internal Maximum Fixed Fee Schedule, most often printed in the policy, or the Reduced or Discounted Fee a that has been Negotiated for the Insurance Company by a Provider Network Company. When a policy states that it will pay its benefit percentage based upon the Provider Network established Reasonable or Allowable Fee, this means you will likely be balanced billed by the dental office for the difference in the Reduced Negotiated Network Fee and the Reasonable and Customary Fee. Understanding that some Provider Network Reduced Fees can be Discounted as much as 50 percent off of the Normal Fee or Current Reasonable and Customary Fee. For example, if the Normal or R&C Fee is $800 and the Allowable Network Fee is $400, and the policy is due to pay 50 percent of the Allowable Fee, the reimbursement would be $200 and the insured would be Balance Billed in the amount of $600. The Insurance Policy ends up only paying 25 percent of the Normal Reasonable and Customary Fee and Not 50 percent because the reimbursement is based on the Network or Plan Allowable Fee, Reduced Discounted or the Negotiated Network Fee. This would be an example of being Out of Network with a 50 percent benefit payable on the Allowable Network Fee.

Additionally, a Dental Insurance Policy that has a Maximum Allowable Fee Schedule will only reimburse the insured member up to the amount shown in the Policies Internal Schedule of Benefits. The Policy may state that it pays 80 or 50 percent of the R&C not to exceed the Schedule of Benefits. The schedule of benefits, or Internal Maximum Allowable Fee Schedule could be only 35 or 40 percent of the normal Reasonable and Customary Fee. Many times the Fixed Fee Schedule is part of the Policy and the Fixed Fees for the services covered are listed, but sometimes the schedule is only available to the Insurance Company and the insured has no idea how much the benefit will be. These Plans are like Co-Payment Plans but since they are indemnified they could be considered a reverse Co-Payment Plan. An example would be: the normal Reasonable and Customary Fee is $800, the Policy pays 50 percent of the R&C not to exceed the Maximum Allowable Schedule of Benefits. On the Policy Internal Schedule of Maximum Allowable Charges the Covered Service is listed for $250. The insureds benefit would be $250. The percentage of the R&C seems to only exist for the benefit of the Insurance Company in the event that if 50 percent of the actual Charged Fee was less then $500, the reimbursement to the insured would be less then the Internal Schedule. Which very rarely ever happens unless in an area where the cost for the covered services were extremely low. The insured would then be responsible for $550. These type of Fixed Internal Schedule of Maximum Allowable Charges Insurance Plans will also use Provider Networks and the Internal Maximum Allowable Fee many times will still be less then the Reduced Network Fee, leaving a balance bill to the insured even when using a provider in the Plan Network.

We hope this information will make you aware of some of the inter-working details pertaining to the Federal Employee Dental Insurance Plans and enables you to make a better decision with a greater  understanding when comparing the available Federal Employee Dental Programs. If you have any questions please feel free to eMail us . Keep Smiling!