Dental Benefits

Question 1

8 basic differences between medicine and dentistry

Answer 1

1. Dentists practice in individual offices, isolation tends to produce a greater variety of dental practice patterns
2. Individuals routinely visit their dentists for preventative care
3. Because of prevention, dental treatment is considered elective and postponed unless there is pain
4. Patient has option to defer treatment or not have it at all
5. Dental care often is cosmetic
6. Dentistry often offers a variety of alternative procedures
7. Dental expenses are generally lower, more predictable, and budgetable
8. Preventative care may be more productive in dentistry than in medicine.

Question 2

Is dental coverage an essential benefit for adults under the ACA?

Answer 2

No, however it is an essential health benefit (EHB) that must be made available by those individual policies and group plans subject to the EHB provisions of the health care reform law.

Question 3

What organizations provide dental care coverages?

Answer 3

Insurance Companies

Blue Cross and Blue Shield associations

Others - including state dental assoc. plans (delta plan), self insured, self-administered plans, and group practice or HMO type plans.

Question 4

What is the breakdown of coverage population

Answer 4

Delta plans - Over 31%
MetLife (insurance company) - 12%
BCBS - < %12
All other carriers less than 10%

Question 5

Discuss how dental plans resemble today’s medical plans - 3 basic approaches

Answer 5

1. Fee-for-service indemnity approach
2. Preferred provider organization approach
3. Dental heath maintenance organization approach

Question 6

10 professional treatment categories into which virtually all dental problems are places

Answer 6

1. Diagnostic
2. Preventative
3. Restorative
4. Endodontics
5. Periodontics
6. Oral Surgery
7. Prosthodontics
8. Orthodontics
9. Pedodontics
10. Implantology

Question 7

Diagnostic

Answer 7

Routine oral exam and x-rays

Question 8

Preventative

Answer 8

Preserve and maintain dental health

Question 9

Restorative

Answer 9

Repair and reconstruction of natural teeth

Question 10

Endodontics

Answer 10

Treatment of dental-pulp disease and therapy such as root canals

Question 11

Periodontics

Answer 11

treatment of the gums and other supporting structures such as curettage and root planning

Question 12

Oral Surgery

Answer 12

tooth extraction and other surgery of the mouth and jaw

Question 13

Prosthodontics

Answer 13

Construction, repair and replacement of missing teeth, crowns, and bridges

Question 14

Orthodontics

Answer 14

Correction of malocclusion and abnormal tooth position

Question 15

Pedodontics

Answer 15

treatment of children who do not have all their permanent teeth

Question 16

Implantology

Answer 16

use of implants and related services such as overdentures, fixed prostheses attached to implants and the like to replace one of all missing teeth on an arch

Question 17

What is palliative treatment

Answer 17

Procedures to minimize pain, including anesthesia, emergency care and consultation

Question 18

Identify the general groupings of dental procedures that are used in the design of dental plans

Answer 18

1. Preventative and diagnostic procedures
2. Minor restorative procedures
3. Major restorative work, endodontic and periodontic services
4. Orthodontic expenses
5. Today’s typical plans often exclude implantology services because of the expense involved

Question 19

How does a schedule plan operate

Answer 19

Pay fixed allowance for each procedure.

Plan might pay $50 for a cleaning and $400 for root canal therapy

May include deductibles-coinsurance provisions are rare

Question 20

Advantages of scheduled plans

Answer 20

Cost Control
Uniform payments
Ease in understanding the plan
Employee relations reasons related to employee appreciation of the plan

Question 21

Disadvantages of schedule plans

Answer 21

Benefit levels must be examined periodically to maintain reimbursement objectives

Plan reimbursement levels will vary in different locations according to cost of dental care in that area

If scheduled benefits are set near the maximum of reasonable and customary range, dentists who usually charge less than the prevailing rates mat be influenced to adjust their charges upward.

Question 22

Describe the operation of nonscheduled dental plans

Answer 22

*Most common of plan offerings

Cover some percentage of the reasonable and customary charges (or charges most commonly made by dentists in the community)

Usual customary charge typically is set between the 75th and 90th percentile, with rend being toward the lower number

Nonschedule plans generally include deductible, typically calendar year of $50 or $75

Prevent and diagnostic expense typically are covered either in full or at a very high reimbursement level

Question 23

Advantages or nonscheduled dental plan

Answer 23

Percentage of total cost reimbursed by the plan is uniform

Built in auto adjustment for inflation and also for variations in the relative value of specific procedures

Question 24

Disadvantage of nonscheduled dental plan

Answer 24

Cost control can be a problem because benefit levels adjust automatically for increases in the cost of care in periods of rapidly escalating prices

Once a plan is installed on a nonscheduled basis, opportunities for modest benefit improvements, are limited

Rarely is clear in advance what the specific payment of a particular service will be either to the patent or dentist

Question 25

What is a combination dental plan

Answer 25

Certain procedures are reimbursed on a scheduled basis while other are reimbursed on a nonscheduled basis. Seek to provide a balance between the need to emphasize preventative care and cost control.

Question 26

Incentive dental plan

Answer 26

Attempts to promote, or incent, sound dental hygiene through increasing reimbursement levels.

Designed to encourage individuals to visit dentist regularly

Generally reimburse at one level during the first year, with coinsurance levels typically increasing from year to year only for those who obtained needed treatment in prior years

One approach may be to carry over part or all of any unused annual benefit maximums info future periods

Question 27

Are incentive plans characterized by deductibles?

Answer 27

Not unusual for them to apply on a lifetime basis

Question 28

Identify and describe the several design peculiarities or orthodontic benefits within dental plans

Answer 28

Almost never written without other dental coverage.

Generally rendered only once in an individuals lifetime
Maximums are typically expressed on lifetime basis

Many plans limit to under 19, however a number of plans include adult orthodontics

Common coinsurance level is 50%, varies widely.

Often paid for in installments

Question 29

What are the three factors that affect the cost of a dental plan

Answer 29

1. Design of the plan
2. Characteristics of the covered group
3. Employer’s approach to plan implementation

Question 30

What are the issues to be addressed in designed a dental plan

Answer 30

Type of plan
Deductibles
Coinsurance
Plan Maximums
Treatment of preexisting conditions
Whether covered services should be limited and the questions concerning orthodontic coverage

Question 31

What are advantages of lifetime deductibles

Answer 31

Has the advantage of avoiding the cost to the plan of the accumulated dental neglect of the participants. Individuals are not denied coverage bet merely induced to invest in their own health as a condition precedent for adequate dental coverage

Question 32

What are the disadvantages of lifetime deductibles

Answer 32

1. Promotes early over utilization by those anxious to take advantage of the benefits
2. Once satisfied, lifetime deductibles are of no further value for the presently covered group
3. Introduces employee turnover as an important cost consideration of the plan
4. May result in adverse employee reaction to the plan

Question 33

What are the typical levels of coinsurance or reimbursement provided under dental plans for the various types of dental procedures

Answer 33

Most dental plans are being designed, either through construction of the schedule of the use of coinsurance, so that the patient pays a portion of the costs for all but preventative and diagnostic services.

Intent is to reduce spending

Many believe that employees who participate financially in the plan make better use of it

Question 34

Preventative and diagnostic expenses generally are reimbursed at ___% to ___% of the usual and customary charges, and full reimbursement is quite common.

Restorations, and in some cases replacements, may be reimbursed at ___% to ___%.

Orthodontics, implantology (where covered) and occasionally major replacements have the lowest reimbursement levels, and most plan reimburse no more the ___% to ___% of the usual and customary charges for these procedures.

Answer 34

A. 80%
B. 100%

C. 70%
D. 85%

E. 50%
F. 60%

Question 35

Explain the use of maximum benefit provisions in dental plans

Answer 35

Most plans have a calandar year maximum for nonorthodontic expense and sometimes a separate lifetime maximum. Orthodontic and implantology expenses generally are subject to separate lifetime maximums.

Question 36

Explain the treatment of preexisting conditions under dental plans

Answer 36

The major concern about how to treat preexisting conditions in a dental plan concerns the replacement of teeth extracted prior to the date of coverage.

Question 37

Summarize the impact of various plan designs on dental plan costs

Answer 37

Dental plan costs can be sensitive to changes in certain plan design features. The change in dental plan deductibles has the most significant impact on cost. As much as a 12% reduction in cost can be gained by increasing the deductible from $50 to $100.

The change in benefit maximums has some impact, but it is minor.

Changes in coinsurance have a definite impact, especially changes in the restoration, replacement and orthodontic portions of the plan.

Question 38

List the characteristics of a dental plan’s covered group that should be considered in the cost of the plan

Answer 38

A. Ages of the participants, average charges usually increase from about 30 to 40

B. Distribution by gender, females have higher utilization rates

C. Location of the group

D. Incomes of the participants

E. Occupations of the group members

Question 39

Describe the types of safeguards against adverse selection used by insurance companies in underwriting contributory dental plans

Answer 39

A. Combining dental plan participation and contributions with med plan part

B. Limiting enrollment to a single offering

C. Requiring dental examinations before joining the plan and limiting or excluding treatment for conditions identified in exam

D. Requiring participants to remain in the plan for a specified minimum time before being eligible to drop coverage.

Question 40

How does a predetermination of benefits provision in a dental plan operate?

Answer 40

Requires the dentist to prepare a treatment plan that shows the work and cost before and services begin. Generally required only for non emergency services < $300.

Carrier processes this info to determine how much dental plan will pay.

Question 41

What is a new technique

Answer 41

Once officially recognized by the America Dental Association, generally are covered as any other service under the plan since they are considered another way to deliver already covered services.

Question 42

What is a new procedure

Answer 42

Not covered so readily. Generally, before these services become accepted, the first must be recognized by the American Dental Association as an accepted procedure and must have a proven track record of success.