Dental Claim Costs

Question 1

Dental Claim Costs

Claim Cost Factors (List, Describe)

Answer 1

• Plan = Covered Benefits, Cost-Sharing, Waiting Periods, Period of Coverage
• Network and Reimbursement Levels = Types, Discount Cards, Care Management
• Insured Population

Question 2

Dental Claim Costs

Purpose of Cost-Sharing

Answer 2

• Reduce cost to insurer
• Incent insured to choose less expensive services

Question 3

Dental Claim Costs

Types of Cost-Sharing

Answer 3

• Deductibles
• Coinsurance/Copays
• Maximum Limits (Didn’t get removed by ACA like medical limits)

Question 4

Dental Claim Costs

Provider Reimbursement Types (List, define)

Answer 4

• FFS = paid for each service performed
• Dental PPO Networks = In-network dentists for reduced fees, no balance billing
• Scheduled Plans = Insured pays difference between dentist’s charge and amount allowed by plan
• Capitation = set rate per member, regardless of services performed

Question 5

Dental Claim Costs

Advantages of Discount Cards

Answer 5

• Can offer wider range of solutions and price points
• Keep up with competition

Question 6

Dental Claim Costs

Insured Population Factors (List and Describe impact on claim costs)

Answer 6

• Age/Gender (Varies)
• Geographic Area (Varies)
• No Prior Coverage and Pee-Announcement (High Utilization)
• EE Turnover (Higher turnover = higher cost)
• Occupation
• Participation = (Under 100% = higher cost)

Question 7

Dental Claim Costs

ACA Impact on Dental

Answer 7

• Pediatric oral services are required (coverage varies by state)
• Inclusion of max OOP provision for Medical + Dental
• Little to no subsidy for stand-alone dental

Question 8

Dental Claim Costs

Dental Anti-Selection Considerations

Answer 8

• Controls
  
  • Tiered coinsurance
  • Maximum benefits vary by year of coverage
  • Elimination/Waiting periods
  • Participation requirements
• Multiple Plan Settings
  
  • Those likely to use more services will choose richer plan