Chpt 8 Dental

Question 1

Components of Dental Plan Design

Answer 1

1. Benefit classes
2. 1 Type I (Preventive and Diagnostic)
   
   1. 1.1 Diagnostic services: Oral exams, X-rays, Diagnostic tests, Laboratory exams, Emergency treatment
   2. 1.2 Preventive services: Cleanings, Fluoride, Sealants, Space maintainers
3. 2 Type II (Basic)
   1. 2.1 filings, root canal, gum treatments, oral surgery, anesthesia
4. 3 Type III (Major)
   1. 3.1 Inlays, onlays and crowns, bridges and dentures
5. 4 Type IV - Orthodontics
6. COB provisions avoid duplication with medical plans
7. Coinsurance
   
   3. 1 Typical plan
   4. 1.1 100% for Type I, 80 for Type II, 50 for Type III
   5. 2 Calendar year deductible waived for Type I
   6. 3 Annual maximum
8. Provisions aimed at limiting cost and anti-selection
   
   4. 1 Exclusions: cosmetic, experimental on- the job accidents
   5. 2 Pre-existing conditions limitations

Question 2

Dental Underwriting and rating parameters

Answer 2

1. Group size
   
   1. 1 larger the group, the lower the prices
2. Eligible individuals: employees, spouse, dependent children
3. Minimum participation requirements
4. Employer contributions
5. Other coverages: packaging coverages is favorable from underwriting perspective
6. Demographic (details follow)
7. Waiting and deferral periods
8. Incentive Coinsurance
9. Transferred business

Question 3

Underwriting and rating parameters

- demographics

Answer 3

1. Group with higher female content receive rate loads
2. Age slope flatter than medical, but costs increase by age
3. Area factors
4. Occupation
   
   4. 1 high utilization include actors, teachers, and sport teams
5. Premium
   
   5. 1 2 tier ( employee and dependent)
   6. 2 3 tier (EE, EE+one dependent, EE+2 or more dependents)
   7. 3 4 tier (EE, EE+spouse, EE+children, EE+spouse+children)

Question 4

Group dental reimbursement models and delivery system

Answer 4

1. Indemnity plans
   
   1. 1 maximum per procedure
   2. 2 dentist charging > maximum will bill patient for balance
2. Dental maintainable organization plans (DHMO)
   
   2. 1 (IPA) DHMO plans
   3. 2 “staff model DHMO plans” (Employ their own dentists)
3. Preferred provider plans (PPO)
   
   3. 1 “Managed indemnity plans” or “passive PPOs”
      
      3. 1.1 Contracted fees with participating dentists
      4. 1.2 Reduced OOP encourage network use
   4. 2 “Discounted fee-for-service PPO plans”
      
      3. 2.1 In network providers agreed to a set % discount
   5. 3 “Fee schedule PPO plans”
      
      3. 3.1 dentists agree to a fee schedule rather than a discount
   6. 4 Discount card plans: for ERs not providing DT insurance
   7. 5 “Exclusive provider organizations plans (EPOs)”
      
      3. 5.1 in network-only PPO plans
   8. 6 “Point of Service (POS)”: Choose HMO provider, PPO, or other, at different benefit levels

Question 5

Dental claim practices

Answer 5

1. Predetermination of benefits
2. Least expensive alternate treatment
3. Coordination of benefit
4. Dental review: review difficult claims to ensure necessity
5. Maximum allowable charge or UCR limit