Chapter 18

Question 1

What is the most important element for creating a cost-effective and relatively problem free dental plan?

Answer 1

Plan design

Question 2

What are well-designed dental plans configured to do?

Answer 2

Ensure the efficient allocation of benefit dollars by creating incentives for patients and providers to maintain oral health and treat dental disease

Question 3

What are members free to do in passive PPOs?

Answer 3

Members are free to see any dentist they wish

Question 4

Cost, utilization, and satisfaction among members and providers are greatly affected by how services are (evaluated and rated / classified and paid).

Answer 4

Classified and paid

Question 5

Moving procedures between classes is known as __________.

Answer 5

Class shifting

Question 6

Class shifting for diagnostic and preventive services is (less / more) common than other forms of class shifting

Answer 6

Less common

Question 7

Why is class shifting most widespread for basic restorative services?

Answer 7

The restorative services category is more complex and useful in terms of class-shifting opportunities, plus the potential for cost savings is greater.

Question 8

Why is it especially important to know how non-network providers will be reimbursed under a passive PPO plan?

Answer 8

Non-network reimbursement is a primary tool for encouraging greater use of network dentists and holding beneficiaries financially accountable for going out of network.

Question 9

From the plan perspective, what is the impact of non-network reimbursement approaches?

Answer 9

Can affect cost, the plan’s reputation with providers, and network stability.

Question 10

What is the impact of non-network reimbursement on purchasers?

Answer 10

Affects cost and member satisfaction

Question 11

Payments to non-network dentists are based on the lesser of the_________ or the __________.

Answer 11

Dentist’s charge / PPO fee schedule

Question 12

To collect the difference in their fee and what the plan pays, in most cases dentists are allowed to __________.

Answer 12

Balance bill

Question 13

What metric is a usual, customary and reasonable (UCR) fee based on?

Answer 13

A specific percentile level determined by the administrator

Question 14

A separate fee schedule used for reimbursement to non-network dentists is called __________.

Answer 14

Maximum allowable charge or MAC schedule

Question 15

Along with the rapid growth in the number of enrollees and percent of market share, how else are PPOs changing today?

Answer 15

Many purchasers are switching from passive to active PPOs

Question 16

Active PPOs provide (greater / lesser) options for controlling cost and benefit design.

Answer 16

Greater options

Question 17

Which feature of active PPOs provides greater steerage to lower cost network dentists?

Answer 17

Benefit differentials between in- and out-of-network care.

Question 18

When designing or recommending a particular plan design and network, what is it important to consider?

Answer 18

The unique characteristics of the purchaser and group

Question 19

Changing from a passive PPO to an active PPO can cause (disruption / interruption) for users of the current plan.

Answer 19

Disruption

Question 20

What trade-offs will sponsors and members face in the switch to an active PPO?

Answer 20

Active PPOs involve trade-offs among cost, benefit value, and access to network dentists

Question 21

What does the text suggest very cost-sensitive groups would be willing to accept as a trade-off for a more limited choice of dentists?

Answer 21

Better benefits at a lower price

Question 22

When changing from a passive PPO to an active PPO, (small, locally clustered groups / large, widely dispersed groups) should have little problem with access issues

Answer 22

Small, locally clustered groups

Question 23

Actuarial estimates of utilization and cost are highly dependent on __________.

Answer 23

Demographics

Question 24

When budget constraints and price sensitivity are concerns for the sponsor and members, (passive PPOs / active PPOs) are especially effective for controlling cost.

Answer 24

Active PPOs

Question 25

(Teachers / Fast-food workers) may be more likely to choose a network provider.

Answer 25

Fast-food workers

Question 26

In considering the benefits philosophy of a plan sponsor, paternalistic sponsors who are concerned about disrupting employees may prefer which type of plan?

Answer 26

A passive PPO or an active PPO with nominal steerage

Question 27

What is a risk that occurs when members pay the majority of the premium cost?

Answer 27

Adverse selection

Question 28

What “incentive” would a plan sponsor use to achieve greater cost savings while keeping the current plan design in place?

Answer 28

The “incentive” approach uses the current plan design as the out-of-network benefit and enhances the in-network benefit

Question 29

What is the objective of the “disincentive” approach?

Answer 29

The “disincentive” approach uses current plan design as the in-network benefit and reduces benefits for out-of-network care

Question 30

What are the most effective plan design elements for incentivizing participants to see network dentists?

Answer 30

Deductibles, annual and lifetime maximums and coinsurance.

Question 31

How is the term illusory benefits defined?

Answer 31

Benefits that may look reasonable on paper but in practice are not available to some beneficiaries

Question 32

Why would the incentive approach using the current benefit design for the out-of-network benefit and enhancing the design for in-network care be viewed as a benefit enhancement for members?

Answer 32

No one would be worse off and all would have the option of obtaining better benefits by seeing a network dentist

Question 33

How would some members view the disincentive approach that keeps the current benefit design for the in-network benefit and reduces benefits for non-network care?

Answer 33

Some members would view this approach as a benefit takeaway, but it may be a necessary strategy to reduce costs.

Question 34

What are three plan considerations for adding PPO benefits for a group with no prior coverage?

Answer 34

Consider a plan that (1) has a low or medium benefit level; (2) includes waiting periods; and (3) does not include coverage for orthodontics

Question 35

What does a maximum rollover allow enrollees to do?

Answer 35

Roll over a portion of their unused annual maximum benefit, up to a limit

Question 36

__________ is a popular new design feature that exempts diagnostic and preventive services from counting against the annual maximum, freeing up dollars to be used elsewhere.

Answer 36

Diagnostic and preventive maximum waiver

Question 37

True or False: A dental accident rider may cover certain necessary procedures at or near 100 percent, but the benefit usually includes a lifetime maximum.

Answer 37

True

Question 38

True or False: Unlike medical services, cosmetic services will be subject to tax and thus are not typically covered under a rider.

Answer 38

True

Question 39

What is the targeted patient population for evidence-based plans?

Answer 39

Patients with conditions that place them at greater risk for dental disease and/or increased severity of existing medical conditions (due to untreated dental conditions)

Question 40

Evidence-based plans often waive (cost sharing / frequency limits / both) for extra cleaning and/or periodontal treatments for pregnant women, those with Type II diabetes, history of cardio-vascular disease, stroke, and other conditions linked to oral health

Answer 40

Both cost sharing and frequency limits