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GBA 1 > Module 5 - Dental Plan Design > Flashcards

Module 5 - Dental Plan Design Flashcards

1
Q

(A) Differences Between Medicine and Dentistry Plan Design

4 Types of Differences

A

1 - Practice Location
2 - Nature of Care
3 - Cost
4 - Emphasis on Prevention

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2
Q

(A1) Differences Between Medicine and Dentistry Plan Design

4 Types of Differences

LOCATION

A
  • The typical physician practices in a group while many dentists practice almost exclusively in individual offices
  • Participating in isolation does not afford the same opportunities for peer review and general qualify control
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3
Q

(A2) Differences Between Medicine and Dentistry Plan Design

4 Types of Differences

CARE

A
  • Because of the importance of preventive dentistry, the need for dental care is almost universal to ensure sound oral hygiene.
  • Individuals routinely visit their dentist for preventive dental care, but in medicine the patient typically visits a physician with certain symptoms - pain or discomfort - and seeks relief.
  • Dental treatment is often considered elective and is classified to be primarily cosmetic - crown, orthodontics.
  • Dentistry often offers alternative procedures for treating disease and restoring teeth, many of which are equally effective.
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4
Q

(A3) Differences Between Medicine and Dentistry Plan Design

4 Types of Differences

COST

A
  • Because major dental care is not life threatening or time critical, dentists charges for major courses of treatment are often discussed in advance of the treatment when there is no pain or trauma
  • the patient may opt to defer the treatment to a later time or spend the money elsewhere
  • Plan design; cost of typical treatment and the emphasis on prevention
  • Dental expense are generally lower, more predictable, and budgetable than medical expenses
  • Average dental claim check is $155
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5
Q

(A4) Differences Between Medicine and Dentistry Plan Design

4 Types of Differences

PREVENTION

A
  • Medical diseases and injuries are self healing while dental disease once started almost always gets progressively worse
  • Preventive care in dentistry may be more productive than in medicine
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6
Q

(B1) Providers of Dental Benefits

3 Categories

A

1 - Insurance Companies
2 - BlueCross BlueShield Organizations
3 - Others such as state dental association plans (Delta Plans), self-insured, self-administered plans and group practice or HMO-type plans.

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7
Q

(B1) Providers of Dental Benefits

3 Categories

Insurance Companies

A
  • MetLife, insures approximately 12% of the market, a share slightly larger than the BlueCross BlueShield plans
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8
Q

(B1) Providers of Dental Benefits

3 Categories

BlueCross BlueShield Organizations

A

.

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9
Q

(B1) Providers of Dental Benefits

3 Categories

Others such as state dental association plans (Delta Plans), self-insured, self-administered plans and group practice or HMO-type plans.

A
  • The Delta plans currently have the largest single market share, insuring over 31% of the covered population
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10
Q

(B2) Providers of Dental Benefits

3 Basic Design Structures

A

1 - The Fee for Service Indemnity or Reimbursement Approach - gradually disappearing
2 - The Preferred Provider (PPO) Approach - this is the prevailing dental benefit approach
3 - The Dental Health Maintenance Organization (DHMO) - gradually disappearing

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11
Q

(C) Covered Dental Expenses

10 Total Covered Dental Expenses

A 
1 - Diagnostic 
2 - Preventive 
3 - Restorative 
4 - Endodontics 
5 - Periodontics 
6 - Oral Surgery 
7 - Prosthodontics 
8 - Orthodontics 
9 - Pedodotnics 
10 - Implantology
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12
Q

(C1) Covered Dental Expenses

10 Total Covered Dental Expenses

Diagnostic

A

Examination to determine the existence of oral disease or to evaluate the condition of the mouth

Example - x-rays and routine oral exams

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13
Q

(C2) Covered Dental Expenses

10 Total Covered Dental Expenses

Preventive

A

Procedures to preserve and maintain dental health

Examples - topical fluoride, cleaning, space maintainers

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14
Q

(C3) Covered Dental Expenses

10 Total Covered Dental Expenses

Restorative

A

Procedures for the repair and reconstruction of natural teeth

Examples - removal of dental decay, fillings

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15
Q

(C4) Covered Dental Expenses

10 Total Covered Dental Expenses

Endodontics

A

Treatment of dental pulp disease and therapy within existing teeth

Examples - root canals

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16
Q

(C5) Covered Dental Expenses

10 Total Covered Dental Expenses

Periodontics

A

Treatment of the gums and other supporting structures of the teeth, primarily for maintenance or improvement of the gums.

Examples - root planing and periodontal curettage

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17
Q

(C6) Covered Dental Expenses

10 Total Covered Dental Expenses

Oral Surgery

A

Tooth extraction and other surgery of the mouth and jaw

Examples - wisdom teeth

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18
Q

(C7) Covered Dental Expenses

10 Total Covered Dental Expenses

Prosthodontics

A

Construction, replacement, and repair of missing teeth.

Examples - onlays, crowns, bridges which are fixed protheses and dentures which are removable protheses

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19
Q

(C8) Covered Dental Expenses

10 Total Covered Dental Expenses

Orthodontics

A

Correction of malocclusion and abnormal tooth position through repositioning of natural teeth

Examples - braces

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20
Q

(C9) Covered Dental Expenses

10 Total Covered Dental Expenses

Pedodontics

A

Treatment for children who do not have all of their permanent teeth

21
Q

(C10) Covered Dental Expenses

10 Total Covered Dental Expenses

Implantology

A

Use of implants and related services (over-dentures, fixed protheses attached to implants, etc.) to replace one or all missing teeth on an arch

22
Q

(C11) Covered Dental Expenses

10 Total Covered Dental Expenses

Pallative Treatment

A

Procedures to minimize pain, including anesthesia

23
Q

(D) Types of Dental Plans

5 Types

A 
1 - Scheduled Plans 
2 - Non-Scheduled Plans 
3 - Combination Plans 
4 - Incentive Plans 
5 - Plans Providing Both Medical and Dental Coverage

*The above are divided broadly into two types of plans - Scheduled and Non-Scheduled Plans

24
Q

(D1) Types of Dental Plans

Scheduled Plans

A
  • Categorized by a listing of fixed allowances by procedure
  • Example; plan pays $50 for a cleaning and $400 for a root canal
  • Plan may include deductibles (small amount or in some cases required on a lifetime basis) and coinsurance (extremely rare)
25
Q

(D1A) Types of Dental Plans

Advantges of Scheduled Plans

A

1 - Cost Control; benefit levels are fixed and therefore less susceptible to inflationary increases

2 - Uniform Payments; may be important to provide the same benefit regardless of regional cost differences. Collectively bargained plans may occasionally take this approach to ensure the “equal treatment” of all members

3 - Ease of Understanding; clear to both the plan participant and the dentist how much is to be paid for each procedure

26
Q

(D1B) Types of Dental Plans

Disadvantages of Scheduled Plans

A

1 - Benefit levels and internal relationships must be examined periodically and changed when necessary to maintain reimbursement objectives

2 - Where participates are dispersed geographically, plan reimbursement levels will vary according to the cost of dental care in a particular area unless multiple schedules are utilized

3 - If scheduled benefits are established at levels that are near the maximum of the reasonable and customary range, dentists who normally charge at below prevailing levels may be influenced to adjust their changes

27
Q

(D2) Types of Dental Plans

Non-Scheduled Plans

A
  • the most common design
  • also referred to as “comprehensive plans”
  • written to cover some % of the reasonable and customary charges, or the charges most commonly made by dentists in the community
  • the U&C charge usually is set between 75th and 90th percentiles; trend is toward the lower number
  • typically include a deductible of $50 or $75 per calendar year
  • Preferred provider benefits are usually provided on an unscheduled basis
28
Q

(D2A) Types of Dental Plans

Advantages of Non-Scheduled Plans

A

1 - Uniform Reimbursement Level; while the dollar payment may vary by area and dentist, the percent of the total cost reimbursed by the plan is uniform (100% preventive, 80% basic, etc.)

2 - Adjusts automatically for change; plan adjusts automatically, not only for inflation but also for variations in the relative value of specific procedures

3 - Relative ease of understanding

29
Q

(D2B) Types of Dental Plans

Disadvantages of Non-Scheduled Plans

A

1 - Because benefit levels adjust automatically for increases in the cost of care, in periods of rapidly escalating prices cost control can be a problem

2 - Once a plan is installed on the basis, the opportunities for modest benefit improvements are limited, at least relative to the scheduled approach

3 - Except for claims in which predetermination of benefits are appropriate, it is rarely clear in advance what the specific payment for a particular service will be, either to the patient or the dentist

30
Q

(D3) Types of Dental Plans

Combination Plans

A
  • variation of scheduled and non-scheduled plans; hybrid plan
  • procedures are reimbursed on both a scheduled and non-scheduled basis
  • preventive and diagnostic coverage provided on a non-scheduled basis (% of U&C, normally without a deductible)
  • procedures outside of preventive and diagnostic are covered on a scheduled basis
31
Q

(D3A) Types of Dental Plans

Advantages of Combination Plans

A

Provides a balance between

1 - the need to emphasize preventive care

and

2 - cost control

32
Q

(D3B) Types of Dental Plans

Disadvantages of Combination Plans

A

1 - benefit levels (excluding preventive and diagnostic) must be evaluated periodically
2 - scheduled payments do not reimburse at uniform levels for geographically dispersed participants
3 - dentists may be influenced by the schedule allowances to adjust their charges
4 - actual plan payments for preventive and diagnostic expenses are rarely identified in advance
5 - more complex than the scheduled or non-scheduled alternatives

33
Q

(D4) Types of Dental Plans

Incentive Plans

A
  • promotes sound dental hygiene through increasing reimbursement levels
  • incentive coinsurance provisions only apply to preventive and maintenance procedures with other procedures covered on either a scheduled or non-scheduled basis
  • generally reimburse at one level during the first year, with coinsurance levels increasing from year to year only for those who obtained needed treatment in prior years
  • deductible may be implied on a lifetime basis
34
Q

(D4A) Types of Dental Plans

Advantages of Incentive Plans

A

1 - encourages regular dental care and reduces the incidence of more serious dental problems in the future
2 - generally have lower first year costs than most non-scheduled plans

35
Q

(D4B) Types of Dental Plans

Disadvantages of Incentive Plans

A

1 - complicated to explain and administer
2 - little evidence exists to suggest that the incentive approach is effective in promoting sound dental hygiene
3 - vulnerable to misunderstanding

36
Q

(D5) Types of Dental Plans

Plans Providing Both Medical and Dental Coverage

A
  • characterized by a common deductible amount that applies to the sum of both medical and dental expenses
  • coinsurance levels may be identical and sometimes the maximum applies to the combination of medical and dental
  • recent design of these plans has made a distinction dental and medical expenses so that each may have its own coinsurance provisions and maximums
  • must be written by a medical carrier
  • fails to recognize the difference between medicine and dentistry unless special provisions are made for dental benefits
37
Q

(D5A) Types of Dental Plans

Advantages of Plans Providing Both Medical and Dental Coverage

(same as non-scheduled plans)

A

1 - Uniform Reimbursement Level; while the dollar payment may vary by area and dentist, the percent of the total cost reimbursed by the plan is uniform (100% preventive, 80% basic, etc.)

2 - Adjusts automatically for change; plan adjusts automatically, not only for inflation but also for variations in the relative value of specific procedures

3 - Relative ease of understanding

38
Q

(D5B) Types of Dental Plans

Disadvantages of Plans Providing Both Medical and Dental Coverage

(same as non-scheduled plans)

A

1 - Because benefit levels adjust automatically for increases in the cost of care, in periods of rapidly escalating prices cost control can be a problem

2 - Once a plan is installed on the basis, the opportunities for modest benefit improvements are limited, at least relative to the scheduled approach

3 - Except for claims in which predetermination of benefits are appropriate, it is rarely clear in advance what the specific payment for a particular service will be, either to the patient or the dentist

39
Q

(E) Orthodontic Expenses

A
  • only rendered once in an individual’s lifetime
  • deductibles and maximums are expressed on a lifetime basis
  • coinsurance is typically 50%; common for the coinsurance amount to be same as the major services coinsurance amount
  • usually paid in installments instead of at the conclusion of the course of treatment
40
Q

(F) Implantology and It’s Services

A
  • dental plans often exclude implants because it is expensive and sometimes unnecessary (cosmetic)
  • generally rendered only once in an individuals lifetime, typically at the same level of deductible and coinsurance as orthodontic services
  • benefits are not typically extended to children
41
Q

(G) Factors Affecting The Cost of The Dental Plan

4 Factors

A

1 - Plan Design
2 - Characteristics of the Covered Group
3 - Sponsors Approach to Implementation
4 - Plan Administration

42
Q

(G1) Factors Affecting The Cost of The Dental Plan

Plan Design

A
  • Must determine type of plan, deductibles, coinsurance, plan maximums, treatment of pre-existing conditions, whether covered services should be limited, and orthodontic coverage
  • an employers objectives will determine if the plan will be scheduled or non-scheduled
  • deductible eliminates frequent payments for small claims that can be readily budgeted; examples - a $50 deductible can eliminate as much as 10% of the number of claims and can therefore effectively control the cost of claims administration
43
Q

(G1A) Factors Affecting The Cost of The Dental Plan

Plan Design

Opponents of the lifetime deductible concept claim the following 4 disadvantages

A

1 - promotes early over utilization by 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 - 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

44
Q

(G1B) Factors Affecting The Cost of The Dental Plan

Plan Design

Pre-Existing Conditions

A

1 - May be excluded
2 - May be treated as any other condition
3 - may be covered on a limited basis (perhaps one half of the normal reimbursement level) or subject to a lifetime maximum

45
Q

(G2) Factors Affecting The Cost of The Dental Plan

Characteristics of the Covered Group

A
  • Age
  • Gender; women have higher utilization (5%) than men
  • Location
  • Income Level of the Participants
  • Occupation; blue collar employees are 15% - 25% less expensive to insure than white collar employees
46
Q

(G3) Factors Affecting The Cost of The Dental Plan

Sponsor’s Approach to Implementation

A
  • dental work, unlike medical care, lends itself to “sandbagging”; deferral of needed treatment until after the plans effective date
  • plans announced well in advance of the effective date tend to have poorer 1st year experience than plans announced shortly before the effective date
  • discourage contributory plans; adverse selection safeguards 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 exam before joining the plan and limiting or excluding treatment for conditions identified in the examination. HIPAA limitations do not apply as long as the dental benefits are “limited in scope” and are available under a separate policy or rider
    4 - requiring participants to remain in the plan for a specified minimum time period before being eligible to drop coverage
47
Q

(G4) Factors Affecting The Cost of The Dental Plan

Plan Administration

A
  • most important consideration
  • “predetermination of benefits” - requires the dentist to prepare a treatment plan that shows the work and cost before services are rendered; required only for non-emergency services and only if the cost is expected to exceed a specific level (example - $300)
  • predetermination of benefits promotes better quality care and reduces costs by spotting unnecessary expenses, treatments that cannot be expected to last, instances of coverage duplication, and charges higher than U&C before extensive and expensive work begins.

-alternate treatment provisions; enable the plan admin either to approve the least costly, equally effective treatment option or to cover more expensive procedures only at the level of less expensive alternative

48
Q

(H) Technology and Dental Plan Design

A
  • the goal is to provider treatment and techniques that are more efficient, more effective, and/or more confirmable.
  • in plan design, important to differentiate between new techniques and new procedures

GBA 1 (11 decks)

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