Dental, Vision And Hearing Care Benefits

Question 1

What organizations provide dental care coverages?

Answer 1

Organizations providing dental care coverage may be separated into three categories:

Insurance companies; Blue Cross and Blue Shield associations; and others, including State dental Association plans (for example, Delta plans) self-insured, self-administered plans and group practice for health maintenance organization (HMO)- type of plans.

The Delta plans currently cover the largest share (over 31%) of the population. One insurance company, MetLife, ensures approximately 12% which is slightly higher than the Blue Cross and Blue Shield plans. All other carriers cover last and temper cent of the market.

Question 2

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Answer 2

The types of dental plans resemble today’s medical plans. There are three basic approaches: the fee-for-service indemnity approach, the preferred provider organization approach and the dental health maintenance organization approach.

As with medical plans, the preferred provider organization is the prevailing dental benefit approach, and the fee-for-service approach is gradually disappearing.

Question 3

Identify and describe the 10 professional treatment categories into which virtually all dental problems are placed.

Answer 3

The 10 professional treatment categories of dentistry are:

1) Diagnostic - routine oral examination and x-rays to determine the existence of oral disease and evaluate the condition of an individual’s mouth.
2) Preventive - procedures to preserve and maintain dental health including cleaning, space maintainers, topical fluoride applications and the like.
3) Restorative - procedures for the repair and reconstruction of natural teeth including the removal of decay and installation of fillings.
4) Endodontics - treatment of dental pulp disease and therapy such as root canal treatments.
5) Periodontics - treatment of the gums and other supporting structures of the teeth such as periodontal curettage and root planing.
6) Oral surgery - tooth extraction and other surgery of the mouth and jaw.
7) Prosthodontics - construction, repair and replacement of missing teeth including fixed prostheses such as inlays, crowns and bridges and removable prostheses such as bridges and dentures.
8) Orthodontics - correction of malocclusion and abnormal tooth position through the repositioning of natural teeth.
9) Pedodontics - treatment of children who do not have all their permanent teeth.
10) Implantology - use of implants and related services such as overdentures, fixed prostheses attached to implants and the like to replace one or all missing teeth on an arch.

In addition to treatment or services and most of these areas, the typical dental plan includes provisions for palliative treatment (that is, procedures to minimize pain, including anesthesia), emergency care and consultation.

Question 4

How does a scheduled dental plan operate?

Answer 4

Scheduled plans pay a fixed allowance for each dental procedure. For example, the plan might pay $50 for a cleaning and $400 for root canal therapy. A scheduled plan may include deductibles. When deductibles are included in scheduled plans, the deductible amounts usually are small or in some cases, required on the lifetime basis only. Coinsurance provisions are rare in scheduled plans since the benefits of coinsurance can be achieved through the construction of the schedule by setting the level of reimbursement for each procedure to reflect specific reimbursement objectives.

Question 5

What are the advantages of a scheduled dental plan?

Answer 5

The advantages of schedule dental plans include:

• cost control
• uniform payments
• ease in understanding the plan
• employee relations reasons related to employee appreciation of the plan

Question 6

What are the disadvantages of a scheduled dental plan?

Answer 6

Disadvantages of scheduled dental plans include:

• benefit levels must be examined and potentially changed periodically to maintain reimbursement objectives
• plan reimbursement levels will vary in different locations according to cost of dental care in that area unless multiple schedules are utilized.
• if scheduled benefits are set near the maximum of the reasonable and customary range, dentists who usually charge less than the prevailing rates may be influenced to adjust their charges upward.

Question 7

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

Answer 7

The 10 general treatment categories of dentistry are placed into three, four and sometimes five general groupings for purposes of the design of dental plans. These are:

1) preventive and diagnostic procedures
2) minor restorative procedures
3) often combined with (2), includes major restorative work (for example, prosthodontics, Endodontics and periodontic services and oral surgery.
4) orthodontic expenses
5) today’s typical plans often exclude implantology services because of the expense involved in covering some of these services. Whether and to what extent to cover implantology often is a separate, cost driven, design decision. If covered, implantology services typically fall into the major restorative grouping although these services sometimes are covered under a separate fifth classification.

Pedodontic care generally falls into the first two groupings, as indicated, the second and third groupings often are combined.

Question 8

Describe the basic differences between medicine and dentistry.

Answer 8

There are many differences between medicine and dentistry that generally include:

A. Physicians typically practicing groups, while many dentists practice almost exclusively an individual offices. This isolation tends to produce a greater variety of dental practice patterns that exist in medicine, and doesn’t allow for the same opportunities for peer review and general quality control.

B. Many individuals may require only preventive or no medical care for years, but because of the need for preventive dentistry, the need for regular dental care is almost universal to ensure sound oral hygiene. So, individuals routinely visit their dentist for preventive dental care, but in Madison a patient may visit a physician only with certain symptoms.

C. Because of its emphasis on prevention, dental treatment often is considered elective and is sometimes postponed unless there is a pain or trauma. Because there is no life-threatening urgency, the patient may postpone treatment.

D. Because the need for major dental care is neither life-threatening nor time critical, dentists charge for major courses of treatment can be discussed in advance of the treatment allowing the patient the option of deferring the treatment or not having it at all.

E. While medical care is rarely cosmetic, dental care often is.

F. Dentistry often offers a variety of alternative procedures for the treatment of disease and the restoration of teeth that may be equally effective that can vary widely in their degree of complexity and cost.

G. Dental expenses generally are lower, more predictable and budget a ball, with the average medical claim being much higher than the average dental claim.

H. There is greater emphasis on prevention in dentistry then in medicine. Notwithstanding the current trend toward prevention in medicine by managed-care medical plans, it’s value is difficult to quantify, while the advantages of preventive dentistry are clearly documented. This is because preventive care may be more productive in dentistry then in medicine, and the value of preventive dentistry relative to its cost is acknowledged.

Question 9

Describe the operation of nonscheduled dental plans.

Answer 9

By far the most common of dental offerings nonscheduled dental plans cover some percentage of the reasonable (usual) and customary charges, or the charges most commonly made by dentists in the community. For any single procedure, the usual and customary charge typically is set between the 75th and the 90th percentile with the trend being toward the lower number. This means that the usual and customary charge level will cover the full cost of the procedure for 75% to 90% of the claims submitted in that geographical area.

Nine scheduled plans generally include a deductible, typically a calendar year deductible of $50 or $75 and they reimburse at different levels for different classes of procedures. Preventive and diagnostic expenses typically are covered either in full or at very high reimbursement levels. Reimbursement levels for other procedures usually are then scaled down from the preventive and diagnostic level, based on the plan design objectives of the employer.

Question 10

What are the advantages of nonscheduled dental plans?

Answer 10

One advantage of nonscheduled plans is that although the dollar payment may vary by area and dentist, the percentage of total cost reimbursed by the plan is uniform. Another is that there is a built in automatic adjustment for inflation and also for variations in the relative value a specific procedures.

Question 11

What are the disadvantages of nonscheduled dental plans?

Answer 11

There are three distinct disadvantages associated with nonscheduled plans:

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

Second, once a plan is installed on as nonscheduled basis, the opportunities for modest benefit improvements, made primarily for employee relations purposes, are limited.

Third, except for claims for which pre-determination of benefits is appropriate, it rarely is clear in advance what the specific payment of a particular service will be either to the patient or the dentist.

Question 12

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Answer 12

A combination dental plan is one in which certain procedures are reimbursed on a scheduled basis, while others are reimbursed and a nonscheduled basis. These types of plans seek to provide a balance between the need to emphasize preventive care and cost control. The combination approach shares many of the same disadvantages as scheduled and nonscheduled plans, at least for certain types of expenses.

Question 13

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

Answer 13

Orthodontic benefits are almost never written without other dental coverage. Because properly treated orthodontic problems are unlikely to recur once they have been corrected, they generally are rendered only ones in an individual’s lifetime. Therefore, maximums typically are expressed on a lifetime basis. There are often no deductibles since a major purpose of the deductible - to eliminate small, new since type claims - is of little consequence for these types of claims. Many plans limit orthodontic coverage to persons under age 19. However a number of plans do include adult orthodontics as well.

A common coinsurance level for orthodontia expenses is 50%, but this varies widely among plans. It is common for the orthodontic reimbursement level to be the same as that for major restorative procedures. Unlike most other benefits, orthodontia is often paid for in installments, because the course of treatment typically extends over several years.

Question 14

Identify the three factors that affect the cost of a dental plan.

Answer 14

The cost of a dental plan is affected by the design of the plan, characteristics of the covered group and the employers approach to plan implementation.

Question 15

Identify the issues to be addressed in designing a dental plan.

Answer 15

There are several issues to be addressed in the design of a dental plan. Included are the type of plan, deductibles, coinsurance, plan maximums, treatment of pre-existing conditions, whether covered services should be limited and the questions concerning orthodontic coverage.

Question 16

Explain the different opinions on the use of deductibles and dental plans.

Answer 16

Deductibles may or may not be included in the design of a dental plan. When they are, they usually are written on the calendar year basis, but they sometimes are written on a lifetime basis. Because numerous dental procedures involve very little expense, the deductible eliminates frequent payments for small claims that can be budgeted for, thereby controlling the cost of claims administration. On the other hand, evidence exists that early detection and treatment of dental problems produces if you were claims in the long term. Many insurers believe the best way to promote early detection is to pay virtually all the cost of preventive and diagnostic services, and therefore they do not subject these services to a deductible.

Question 17

What are the advantages of lifetime deductibles?

Answer 17

Proponents of a lifetime deductible and dental plans claim that it has the advantage of avoiding the cost to the plan of the accumulated dental neglect of the participants. In addition they claim that individuals are not denied coverage but merely induced to invest in their own dental health as a condition precedent for adequate dental coverage.

Question 18

What are the disadvantages of lifetime deductibles?

Answer 18

Those who oppose the use of a lifetime deductible clean the following for disadvantages:

1) A lifetime deductible promotes early overutilization buy those anxious to take advantage of the benefits of the plan.
2) Once satisfied, lifetime deductibles are of no further value for the presently covered group.
3) The lifetime deductible introduces employee turnover as an important cost consideration of the plan.
4) If established at a level that will have a significant impact on claim costs and premium rates, a lifetime deductible may result in adverse employee reaction to the plan.

Question 19

Explain the typical levels of coinsurance for reimbursement provided under dental plans for the various types of dental procedures.

Answer 19

Most dental plans are being designed, either through construction of the schedule for the use of coinsurance, so that the patient pays a portion of the cost for all but preventive and diagnostic services. The intent is to reduce spending an optional dental care and to provide cost effective dental practice. Also, many believe that employees who participate financially in the plan make better use of it. The following are typical reimbursement levels provided under dental plans for the various types of dental procedures.

Preventive and diagnostic expenses generally are reimbursed at 80% to 100% of the usual and customary charges, and full reimbursement is quite common.

Restorations, and in some cases replacements, may be reimbursed at 70% to 85%. In other cases, the reimbursement level for replacements is lower then for restorative treatment.

Orthodontics, implantology (where covered) and occasionally major replacements have the lowest reimbursement levels, and most plans reimbursed no more than 50% to 60% of the usual and customary charges for these procedures.

Question 20

Explain the use of maximum benefit provisions and dental plans.

Answer 20

Most plans have a calendar year maximum for nonorthodontic expenses and sometimes a separate lifetime maximum. Orthodontic and implantology expenses generally are subject to separate lifetime maximum’s.

Unless established at a fairly low level, a lifetime maximum will have little or no impact on claim liability and only complicates plan design. Calendar your maximums, though, encourage participants to seek less costly care and may help spread out the impact of accumulated dental neglect over the early years of the plan. The typical calendar year maximum is somewhere between $1000 and $1500.

Question 21

Explain the treatment of pre-existing conditions under dental plans.

Answer 21

The major concern about how to treat pre-existing conditions in the dental plan concerns the replacement of teeth extracted prior to the date of coverage. Pre-existing conditions are handled in several different ways. They may be excluded, treated as any other condition, or covered on a limited basis (for example, coverage on one half the normal reimbursement level) or subject to a lifetime maximum.

Question 22

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Answer 22

The range of procedures to be covered under a dental plan is an important design consideration. In addition to orthodontics and implantology, other procedures occasionally excluded are surgical periodontics and temporomandibular joint (TMJ) dysfunction therapy. Although rare, some plans cover only preventive and maintenance expenses.

Question 23

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Answer 23

Dental plan cost 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 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 the amount of coinsurance have a definite of fact, especially changes in the restoration, replacement and orthodontic portions of the plan, all of which represent about 80% to 85% of the typical claim costs. Finally the inclusion of orthodontics in the base plan is another item a fairly high cost.

Question 24

List the characteristics of a dental plans covered group that should be considered in the cost of the plan.

Answer 24

There are several important characteristics of the Covert group that should be considered in the cost of the dental plan these include:

1) Ages of the participants because average charges usually increase from about age 30 to 40.
2) The distribution by gender of the group because females tend to have higher utilization rates than males.
3) The location of the group because dental charges, practice patterns and the availability of dentists vary by locale. Differences exist in the frequency of use for certain procedures as well. Also, the presence of fluoride in the water supply substantially reduces dental costs.
4) The incomes of the participants because there is a discernible increase in costs at higher income levels.
5) The occupations of the group members because blue-collar workers have decidedly lower dental costs then white-collar employees.

Question 25

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

Answer 25

Safeguards used by insurance companies to discourage adverse selection in the underwriting of contributory dental plans include:

1) Combining dental plan participation and contributions with medical plan participation.
2) Limiting enrollment to a single offering, thus preventing subsequent sign-ups or dropouts.
3) Requiring dental examinations before joining the plan and limiting or excluding treatment for conditions identified in the exam. The health insurance portability and accountability act (HIPAA) limitations do not apply as long as the dental benefits are limited in scope and are available under a separate policy or writer.
4) Requiring participants to remain in the plan for a specified minimum time before being eligible to drop coverage.

Question 26

How does a pre-determination of benefits provision in a dental plan operate?

Answer 26

Predetermination of benefits requires the dentist to prepare a treatment plan that shows the work and cost before any services begin. The treatment plan generally is required only for nonemergency services and only if the cost is expected to exceed some specified level such as $300. The carrier processes this information to determine exactly how much the dental plan will pay. Also, selected claims are referred to the carriers dental consultants to assess the appropriateness of the recommended treatment. If there are any questions, the dental consultant discusses the treatment plan with the dentist prior to performing the services.

Question 27

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Answer 27

Dental technology is constantly and rapidly changing. In dental plan design, it is important to differentiate between new techniques and new procedures. A new technique is a different way to provide an already covered service. New techniques, once officially recognized by the American dental Association, generally are covered as any other service under the plan since they are considered another way to deliver already covered services.

New procedures are not covered so readily. Generally, before these services become covered, they must, first, be recognized by the American dental Association as an accepted procedure and, second, must have a proven track record of success. Procedures are then approved for coverage for tabled for further study. If approved, a separate decision establishes whether the procedure and similar ones will be covered routinely or instead as a design option at the plan sponsors direction.

Question 28

Vision care plans typically include what benefits?

Answer 28

Vision care plans usually cover routine eye examinations; certain ocular test such as coordination of eye movements, tonometry, depth perception for children and refraction testing for distance; and near vision. The plans also cover certain products such as lenses, standard type frames and contact lenses.

Question 29

Describe the various approaches to vision care plan design.

Answer 29

Generally plans use frequency limits on the number of times a participant can receive a benefits such as lenses or exams. 12 or 24 months. Are common frequency limits. Vision plans then may use a schedule of benefits approach, preferred provider networks and/or flexible benefits approaches in designing a plan.

A schedule of benefits plan sets maximum dollar limits on the amount that will be paid toward a specific benefit, say $50 for an exam, $60-$140 for lenses depending on their complexity. The plan pays the lesser of the charged amount or maximum.

Preferred provider networks for vision benefits are similar to those for medical care. Participants who use a vision care provider in the network pay a minimum copayment for services and discounted charges for products. There is sometimes coverage for services/products when a nonnetwork provider is used, with reimbursement based on a schedule or usual, customary and reasonable (UCR) charges.

Vision benefits can also be included in a flexible benefit plan. Also, if not covered under a plan, under a flexible spending account, the employee can fund planned vision care expenses (and also dental expenses on a pretax basis). (Vision care, hearing care and dental services expenses qualify for reimbursement under a health savings account (HSA) and a health reimbursement arrangement (HRA).

Question 30

Explain whether hearing care typically is covered by standard surgical and major medical policies.

Answer 30

Surgical procedures affecting the year are normally covered in standard medical policies and generally are included in HMO coverage. In addition, some HMOs, major medical and comprehensive policies include hearing aids. However, more complete coverage is afforded by plans specifically designed to cover hearing care.

Question 31

Describe the types of hearing care benefits typically included in separate hearing care benefit plans.

Answer 31

A common hearing care benefits package includes an 80% reimbursement for services and materials up to a maximum of $300-$600. The frequency of benefit availability is usually every 36 months. Items that often are covered and include (1) otologic examinations (by a physician or surgeon), (2 ) audiometric examinations (by an audiologist) and (3) hearing instruments (including evaluation, earmold fitting and follow up visits.)

Preferred provider plans in which access to a panel would result in discounts for audiologist fees as well as hearing aid instruments also are available. Some service plans apply copayments when participating providers are utilized. Material costs can be reimbursed on a cost-plus-dispensing-fee basis. Additionally, a flexible spending account is a convenient vehicle to take care of hearing care expenses in the absence of benefit coverage.

Question 32

The feature in a dental plan that requires the dentist to prepare a treatment plan showing the work and cost before any service begins is known as a(n):

A.  Advance dental review
B.  Preventive care/maintenance plan
C. Preadmission testing
D. Diagnostic pre-treatment session
E. Predetermination of benefits

Answer 32

E. Predetermination of benefits.

Predetermination of benefits is the term used to describe a feature requiring dentists to prepare a treatment plan before services commence.

Question 33

Which of the following is (are) among the types of plan design approaches that are used to provide dental benefits?

I. Incentive plans
II. Universal plans
III. Combination plans

A.  I only
B.  II only
C.  I and II only
D.  I and III only
E.  II and III only

Answer 33

D. I and IIII only. There are several types of dental plans: (1) scheduled plans, (2) nonscheduled plans, (3) combination plans, (4) incentive plans and (5) plans that provide both medical and dental coverages.

Question 34

Dental plans commonly provide coverage for all of the following treatment categories EXCEPT:

A. Temporomandibular joint dysfunction (TMJ)
B. Minor restorative procedures including endodontics, periodontics and oral surgery.
C. Orthodontic expenses
D. Major restorative work such as prosthodontics
E. Preventive and diagnostic expenses.

Answer 34

A. Temporomandibular joint dysfunction (TMJ) therapy.

TMJ, is a difficult to diagnose disorder often considered a medical condition and sometimes excluded from treatment under a dental plan.