UNIT 19 Flashcards
DIAGNOSTIC AND PREVENTATIVE
routine exams and x-rays, regular cleanings, fluoride treatments
RESTORATIVE
Repairing and restoring teeth that have been damaged, usually by tooth decay; fillings and crowns
ORAL SURGERY
Surgery performed in the oral cavity, example, the removal of wisdom teeth
ENDODONTICS
treatment of the pulp (the soft tissue substance located in the center of each tooth); root canals
PERIODONTICS
treatment of the supporting structures of the teeth– that is, the gums
PROSTHODONTICS
artificial replacements, such as bridges and dental implants
ORTHODONTICS
correction of irregular alignment of the teeth; most commonly, braces
COVERAGE FEATURES
DENTAL
Choice of Provider
-Dental expense plans may be offered under a traditional indemnity plan which places no limits on the insureds choice of dentist. Many dental expense plans are offered through Preferred Provider Organizations PPOs which have contracted with particular dentists to provide services for prearranged fees. In order to get the highest reimbursement rates (80% -100%) on the treatment the insured must choose a dentist that belongs to the PPO network. The insured may go outside the network but the reimbursement rates will be much lower(50%-60%)
SCHEDULED VS NONSCHEDULED PLANS
DENTAL
Some dental expense plans are scheduled; benefits are limited to a specified maximum per procedure, with first dollar coverage., much like basic hospital, medical and surgical plans. Most, however, are nonscheduled plans that pay on a usual, customary, and reasonable (UCR) basis like comprehensive medical expense coverage.
DEDUCTIBLES, COINSURANCE AND LIMITS FOR VARIOUS BENEFIT CATEGORIES
Deductibles, coinsurance and limits often apply differently to various levels of treatment.
-Diagnostic/Preventative services- are usually covered without deductibles or coinsurance to encourage preventative care. However, routine exams and cleanings are generally limited to twice a year and diagnostic x-rays to once every 2 or 3 years.
Basic Services- such as fillings, crowns and local anesthesia may be subject to a deductible and 20% coinsurance or a limit per service in excess of which the insured must pay. There may also be an overall annual limit on benefits for all basic services.
Major services- such as oral surgery, root canals, periodontics, bridges, and implants may be subject to higher coinsurance rate, such as 50% as well as per-service limits.
PREDETERMINATION OF BENEFITS
Most dental expense plans recommend, an a few require, that dentists provide patients with a written treatment plan showing the estimated charge for each service to be performed, along with a breakdown of how much of the cost is expected to be paid by the dental plan, and how much will remain for the insured to pay. Often the recommendation or requirement applies only to treatment that will exceed a certain amount such as $200 or $300. These plans help the insured to evaluate their treatment options and budget for their upcoming treatment.
EXCLUSIONS
DENTAL
The following are typically excluded from coverage under dental expense plans:
- cosmetic treatment
- oral hygiene
- replacement of teeth missing at the time coverage became effective
- completion of services begun before coverage became effective
- replacement of lost dentures, duplicate dentures
- occupational injuries covered by workers’ compensation
- treatment received in government facilities
INTEGRATED DEDUCTIBLE VS STAND ALONE PLAN
DENTAL
In regard to employer group coverage, dental expense coverage may be integrated within a comprehensive health plan or provided as a stand-alone supplement along with a health plan. When integrated into a comprehensive health plan, the dental expense coverage will not have a separate deductible–only the health plan deductible needs to be satisfied. More often, dental expense coverage is offered as a stand -alone supplement with its own deductible and co-insurance requirements.
MINIMIZING ADVERSE SELECTION
DENTAL
Insurers often implement the following restrictions to minimize the increase potential for adverse selection in dental expense plans:
- Probationary periods- a period of time after the employee becomes eligible to join the group plan before dental expense coverage is effective
- Limitations on benefits for late enrollees- those that want to sign up for coverage after the end of the 30 day enrollment period that follows the eligibility period
- Reduced benefit limits during the first year of coverage
- No conversion privilege to convert the dental expense coverage to an individual plan if the group coverage terminates. (however , subject to COBRA rules)
