Dental Benefits Flashcards
Module 5
8 basic differences between medicine and dentistry
- Dentists practice in individual offices, isolation tends to produce a greater variety of dental practice patterns
- Individuals routinely visit their dentists for preventative care
- Because of prevention, dental treatment is considered elective and postponed unless there is pain
- Patient has option to defer treatment or not have it at all
- Dental care often is cosmetic
- Dentistry often offers a variety of alternative procedures
- Dental expenses are generally lower, more predictable, and budgetable
- Preventative care may be more productive in dentistry than in medicine.
Is dental coverage an essential benefit for adults under the ACA?
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.
What organizations provide dental care coverages?
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.
What is the breakdown of coverage population
Delta plans - Over 31%
MetLife (insurance company) - 12%
BCBS - < %12
All other carriers less than 10%
Discuss how dental plans resemble today’s medical plans - 3 basic approaches
- Fee-for-service indemnity approach
- Preferred provider organization approach
- Dental heath maintenance organization approach
10 professional treatment categories into which virtually all dental problems are places
- Diagnostic
- Preventative
- Restorative
- Endodontics
- Periodontics
- Oral Surgery
- Prosthodontics
- Orthodontics
- Pedodontics
- Implantology
Diagnostic
Routine oral exam and x-rays
Preventative
Preserve and maintain dental health
Restorative
Repair and reconstruction of natural teeth
Endodontics
Treatment of dental-pulp disease and therapy such as root canals
Periodontics
treatment of the gums and other supporting structures such as curettage and root planning
Oral Surgery
tooth extraction and other surgery of the mouth and jaw
Prosthodontics
Construction, repair and replacement of missing teeth, crowns, and bridges
Orthodontics
Correction of malocclusion and abnormal tooth position
Pedodontics
treatment of children who do not have all their permanent teeth
Implantology
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
What is palliative treatment
Procedures to minimize pain, including anesthesia, emergency care and consultation
Identify the general groupings of dental procedures that are used in the design of dental plans
- Preventative and diagnostic procedures
- Minor restorative procedures
- Major restorative work, endodontic and periodontic services
- Orthodontic expenses
- Today’s typical plans often exclude implantology services because of the expense involved
How does a schedule plan operate
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
Advantages of scheduled plans
Cost Control
Uniform payments
Ease in understanding the plan
Employee relations reasons related to employee appreciation of the plan
Disadvantages of schedule plans
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.
Describe the operation of nonscheduled dental plans
*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
Advantages or nonscheduled dental plan
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
Disadvantage of nonscheduled dental plan
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
What is a combination dental plan
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.
Incentive dental plan
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
Are incentive plans characterized by deductibles?
Not unusual for them to apply on a lifetime basis
Identify and describe the several design peculiarities or orthodontic benefits within dental plans
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
What are the three factors that affect the cost of a dental plan
- Design of the plan
- Characteristics of the covered group
- Employer’s approach to plan implementation
What are the issues to be addressed in designed a dental plan
Type of plan Deductibles Coinsurance Plan Maximums Treatment of preexisting conditions Whether covered services should be limited and the questions concerning orthodontic coverage
What are advantages of lifetime deductibles
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
What are the disadvantages of lifetime deductibles
- Promotes early over utilization by those anxious to take advantage of the benefits
- Once satisfied, lifetime deductibles are of no further value for the presently covered group
- Introduces employee turnover as an important cost consideration of the plan
- May result in adverse employee reaction to the plan
What are the typical levels of coinsurance or reimbursement provided under dental plans for the various types of dental procedures
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
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.
A. 80%
B. 100%
C. 70%
D. 85%
E. 50%
F. 60%
Explain the use of maximum benefit provisions in dental plans
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.
Explain the treatment of preexisting conditions under dental plans
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.
Summarize the impact of various plan designs on dental plan costs
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.
List the characteristics of a dental plan’s covered group that should be considered in the cost of the plan
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
Describe the types of safeguards against adverse selection used by insurance companies in underwriting contributory dental plans
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.
How does a predetermination of benefits provision in a dental plan operate?
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.
What is a new technique
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.
What is a new procedure
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.