I recently enrolled in a new Cigna PPO Dental plan with out-of-network coverage (I paid extra for this feature). The plan documents stated that I would be covered for 90% of dental expenses with a 10% out-of-pocket cost. However, when I visited the dentist, I discovered that the coverage was only 90% of their discounted amount. For example, for an exam, they only covered $22, leaving me to pay $19.00. This pattern continued for most of my services. Ultimately, I received a few fillings, and they only paid about $100 for the cleaning, exam, x-rays, and fillings, claiming that the rest was not covered. This is the first time I’ve encountered such an issue with a dental plan.
In the fine print, it mentions coverage of their “maximum allowable charge,” which seems to be set at a very low amount. Is there anything I can do about this? Do I have any recourse?
hi stephie incase u get a toothache which requires medical attention urgently, you can Under the Cigna DPPO plan, have the freedom to select any licensed dentist or specialist of your choice. you are not required to choose a primary care dentist or obtain referrals to see a specialist.
Here’s a simplified and humanized version of the text:
This is how out-of-network coverage works for any insurance, whether it’s medical or dental. There are six main dental insurers divided between underwriters (MetLife, Delta, and Cigna) and ACOs (DenteMAX, Careington, Zelis/TDA). Because of this split, the rates don’t vary much, except when you choose a plan that offers access to multiple tiers, like MetLife PDP and PDPPlus.
It’s important to note that out-of-network dentists can do certain things legally that in-network dentists can’t. For example, they can bundle multiple services under one ADA code, such as combining X-rays and gum treatment as part of a “cleaning.” This can reduce your reimbursement by a significant amount.
Additionally, they can perform expensive or semi-cosmetic procedures during the same appointment without needing to submit a Pre-Treatment Estimate (PTE) to the insurer. If a PTE was required and the insurer denies or adjusts the claim, you would have to pay the difference.
Out-of-network dentists might also upgrade (e.g., X-ray to ConeBeam CT) or downgrade (e.g., composite to amalgam filling) a claim based on what will avoid insurance denial.