Lesson 9

Question 1

1.1m Identify services generally provided under government sponsored dental programs (definition +3 specifics)

Answer 1

Surgical dental services which are defined by the CHA as any medically or dentally required services performed by a dentist in a hospital where a hospital is required to properly perform the procedure. Includes:

1) Oral and maxillary facial surgery
2) Routine extraction services provided for patients who are undergoing active treatment in a hospital and the attendant medical procedure requires the removal of teeth
3) All precancerous or cancerous dental surgical biovpsies

Question 2

1.2 Explain why dental benefits are an integral part of a group benefits plan

Answer 2

Dental expenses are an individual’s responsibility.

Question 3

2.1 Explain the significance of IT-339R2 meaning of Private services health plan for dental plans (4) (think insurance)

Answer 3

To qualify a plan must
1)be an undertaking of one person

2) Indemnify another person
3) For an agreed consideration
4) From a loss or liability in respect of an uncertain event

Question 4

2.2 Compare and contrast dental coverage and health coverage (4)

Answer 4

1) dental coverage is more preventative
2) Dental services may be sought for cosmetic reasons
3) dental services often have more time for consideration as issues are less likely to be life threatening
4) The cost of dental care is generally more predictable than health care and there is a lower risk that costs will be catastrophic

Question 5

2.3 Identify 4 group characteristics that affect dental plan utilization

Answer 5

1) Age - Highest among adolescents and lowest among seniors
2) Sex - women have higher utilization rates
3) Location - charge levels, practice patterns, and the availability of dentists vary widely by region
4) Income level - expenditures are higher for members of families with higher income. Going is habit and there are more dentists in more affluent areas

Question 6

2.4 Outline how insurers use dental fee guides and discuss whether dentists must adhere to them

Answer 6

There is no formal requirement for dentists to adhere to fee guides.

Insurers generally use them as basis for determining reasonable and customary charges

Question 7

2.5 Outline the procedure coding system used by most dental associations to establish their fee guides and discuss what territories use it (descrie+5)

Answer 7

The Canadian Dental Association (CDA) has established a code system used across Canada except in Quebec

The code series identifies the category of service by the digit position

1) First digit identifies the category of services
2) Second digit identifies classification of service
3) Third digit identifies sub classification
4) fourth digit identifies the service
5) fifth digit identifies the time required

Codes may change from time to time. The provincial/territorial associations assign a fee for a given procedure and they typically change annually.

Question 8

3.1 Identify fee guide options that insurers might offer to plan sponsors (3)

Answer 8

1) Current year with reimbursement automatically updated annually as new guides are released
2) Lag-fee guide reimbursement (typically 1-2 years behind)
3) Fixed fee guide with reimbursement amounts static until the plan sponsor amends

Question 9

3.2 List the dental services categorized as basic services in a dental plan (13)

Answer 9

1) Recall services including examination, bitewing x-rays, light scaling, cleaning, polishing, topical fluoride
2) Complete examination, emergency or specific examination to evaluate condition and decide treatment
3) x-Rays or panoramic radiographs to diagnose or examine progress
4) Diagnostic tests and lab exams
5) Removal of impacted teeth including anesthesia
6) Space maintainers for primary teeth
7) Pit and fissure sealants
8) Fillings including amalgam, composite and acrylic
9) Removal of teeth except impacted teeth
10) Prefab metal restorations/crowns and repairs
11) Surgery and related anesthesia (except impacted teeth)
12) Endodontics (root canal therapy/fillings, treatment of disease of pulp tissue)
13) Periodontics (treatment of tissues and bones supporting the teeth)

Question 10

3.3 List dental services categorized as major restorative services by dental plans (4)

Answer 10

1) Prosthodontic services and appliances to replace missing teeth and structures with removable artificial appliances
2) Implant supported porcelain crowns and tooth supported porcelain crowns, inlays and onlays
3) Dentures and nonremovable artificial appliances such as bridgework and crowns
4) Repair of dentures, rebase or relined dentures, bridges and dentures (Prosthodontic)

Question 11

3.4 Identify dental services categorized as orthodontic services in dental plans

Answer 11

Procedures required for prevention and correction of dental and oral irregularities and defects of the jaws and dental habits by correction the spacing of teeth

Question 12

3.5 Explain why nonmandatory dental plans are more susceptible to adverse selection

Answer 12

Because they’re non mandatory

Question 13

3.6 Explain how the benefit amount payable for dental services is usually determined

Answer 13

Most dental plans base benefit amounts off of reasonable and customary charges up to the fee guide in effect.

Question 14

4.1 Define calendar year maximum

Answer 14

Limits the amount paid for basic and major restorative services covered per individual per calendar year. Can be combined or separate for basic and major restorative

Question 15

4.1.b Define individual lifetime maximum

Answer 15

Limit for the lifetime of an individual. Usually used for orthodontics

Question 16

4.1.c Define late applicant maximum

Answer 16

Can be applied to some or all categories of services if an individual applies for a non-mandatory plan more than 31 days after becoming eligible.

Group contracts may include a portion that limits benefit amounts for some or all categories for basic services for a period of time (usually 1-3 years)

Question 17

4.2 Identify frequency limitations that may be included in dental plans

Answer 17

Frequency limitations restrict the number of services or the number of units of services that are covered.
Recall exams and the services associated with routine checkups may be limited to once a period (usually a number of months).

Question 18

4.3 Describe replacement limitations that may be included in dental plans

Answer 18

Limits are put on the frequency of replacement for specific prosthodontics.

Dentures, crowns or bridgework are usually only replaced under certain circumstances.

Replacement of temporary dentures with permanent dentures is normally only covered if performed within a certain period of time.

Most plans cover replacing lost, stolen or misplaced appliances

Question 19

4.4 Outline age limitations that may be included in dental plans.

Answer 19

Age limits may be applied throughout the plan.

There may be twice yearly recall exams for those under 19 and once yearly for those older.

Orthodontic treatments may be limited to those under age 19.

Question 20

4.5 Explain the predetermination of benefits provisions in dental plans

Answer 20

Most require preauthorization for procedures that cost more than a predetermined amount.

Evidence to support the treatment may be required. The insurer reviews the evidence and validates the necessity of the treatment. Of denied reasoning is provided.

Treatment must take place within a certain amount of time from approval. (90 days) The amount payable is subject to plan provisions as of the date of service.

Question 21

4.6 Explain the purpose of the alternative benefit provision (ABP) in dental plans

Answer 21

Under ABP expenses are covered up to the usual charge for the least expensive treatment option that will produce a professionally adequate result.

If a more costly treatment is opted for the individual is responsible for additional charges

Question 22

4.7 Outline the benefits that may be continued after termination of insured group dental coverage

Answer 22

Some group contracts allow for continued dental care coverage to dependents of a plan member after the member’s death.

Typically for a max of 2 years.

To qualify dependents must continue to satisfy the definition of dependent. Remarriage means a spouse is no longer eligible and children may age out of the plan.

Question 23

5.1 Describe how plan members are taxed on group dental plan premiums and benefits.

Answer 23

with the exception of Quebec dental premiums paid by the plan sponsor aren’t taxable to the member.

In all jurisdictions benefits aren’t taxable to the plan member regardless of whether the premium was paid by the member or plan sponsor

Question 24

6.1 Contrast the use of deductibles to the use of coinsurance as cost containment approaches in dental plans

Answer 24

Deductibles may be subject to shrinkage in real terms due to inflation and their increase may upset plan members.

If deductibles are applied on an annual basis those who use the plan more pay a smaller proportion than those who use the plan less often. There is no ongoing cost sharing.

Coinsurance has inflation built in and may require less revising. Coinsurance levels may vary by service. Most plan sponsors pay 80%-100% for basic and preventative services and 50%-60% for major restorative and orthodontic services

Question 25

6.2 List cost-containment measures other than lowering coinsurance levels that can be used in dental plans (6)

Answer 25

1) Limiting coverage for certain services (e.g. limit reimbursement of lab fees to 50% of total dental procedure costs)
2) Limiting the frequency of various routine procedures
3) Limiting the frequency of emergency exams (if the limit is exceeded the claim is subject to review by a dental consultant)
4) Increasing the period of time between coverage of replacement crowns.
5) Limiting the number of units allowed for periodontal scaling by a general practitioner. (if the limit is exceeded the claim is subject to review by a dental consultant)
6) Limiting payment to a fixed fee guide or lagged fee guide

Question 26

6.3 Explain how dental plan audits can assist plan sponsors whose dental plan costs are increasing significantly from year to year

Answer 26

May provide insight into the cause of cost increases.

Reviews include eligibility of claimants, plan design and plan experience.

Policy provisions are reviewed for inconsistency in any list of covered codes and plan exclusions.

An audit can verify ABP and make sure that plans for major work were reviewed by the plan’s dental consultant.

Question 27

6.4 Identify types of exclusions in dental plans

Answer 27

1) Services or supplies for cosmetic procedures not a result of an accident
2) Services not provided by legally qualified dentists or denturists acting within scope (except for dental hygienists under direction from a dentist)
3) Experimental treatments
4) Replacement of lost or stolen prosthodontic appliances and devices such as dentures.
5) Certain services relating to treatment that began before the effective date of coverage (eg multi stage restorations)
6) Any services or supplies for which no charge would have been applied in the absence of insurance
7) Services or supplies required as a result of an accidental injury to natural teeth and covered under a EHC plan
8) Any service or supplies covered by government sponsored benefits such as WC
9) Miscellaneous items such as travel, consultation, communication costs, missed appointments
10) Supplies or services to personalize or characterize dentures
11) Services required for a full mouth reconstruction or vertical dimension correction
12) Protective sports appliances
13) Services resulting from intentional self injury, war, or a criminal act

Question 28

7.1 Identify the documentation required when filing a claim for a routine dental procedure in dental plans (timing & 3 things on the form)

Answer 28

Written proof of loss or expense must be submitted within 12-18 months after the date the expense was incurred and no later than 3-12 months after the plan terminates.

The standard form must include:

a) The treatment provided along with the appropriate procedure code.
2) The dentist or qualified practitioner who provided treatment
3) The date on which treatment was provided

Question 29

7.2 Describe assignment of benefits in dental plans

Answer 29

Assignment of benefits authorizes the dentist to collect payment directly from the insurer or TPA.

Convenient since individuals don’t have to pay up front

Question 30

7.3 Describe electronic claims adjudication and it’s benefits

Answer 30

In the Electronic Data Interchange (EDI) system information is transmitted between the dentist and the claims payer to verify coverage and confirm the amount covered.

Can accommodate assignment to the dentist since claims data is only entered once and then automatically filed each time a claim is send.

CDAnet compiles the data exchanged and collected by dental associations and uses it to produce analysis and update fee guides.

Question 31

8.1 Explain how group size influences the method of funding dental plans

Answer 31

small: nonrefund accounting, either pooled or prospectively rated.

Medium: May be refund accounting or self insured

Large: may be refund accounting or self insured with an ASO agreement