Unit 19: Dental Insurance Flashcards
What are the 7 types of coverage are usually included in most dental expense plans?
•diagnostic & preventive-routine exams & x-rays, regular cleanings, fluoride treatments
•restorative-includes fillings & crowns
•oral surgery
•endodontics-treatment of the pulp (soft tissue substance located in the center of each tooth); includes root canals
•periodontics-treatment of the gums
•prosthodontics
•orthodontics
Choice of provider
•dental expense coverage may be offered under a traditional indemnity plan which places no limits on the insured’s choice of dentist
•many dental expense plans offered through PPOs (preferred provider organizations) which have contracted with particular dentists to provide services for pre-arranged fees
What are scheduled plans?
•benefits are limited to a specified maximum per procedure, with a first dollar coverage, similar to basic hospital, medical, & surgical plans
•some dental expense plans are scheduled
What are nonscheduled plans?
•pay on a usual, customary, & reasonable (UCR) basis like comprehensive medical expense coverage
•most dental expense plans are nonscheduled
What are combination plans?
•some dental expense plans combine features of both scheduled (basic) & nonscheduled (comprehensive) plans
•typically cover diagnostic & preventive treatment on a usual, customary, & reasonable basis but use a fee schedule for other dental services
How are diagnostic/preventive services usually covered?
•without deductibles or coinsurance (to encourage preventive dental care)
•routine exams & cleanings are generally limited to twice a year
•diagnostic x-rays generally limited to once every 2 or 3 years
How are basic services, such as fillings, crowns, and local anesthesia, usually covered?
•may be subject to a deductible & 20% coinsurance or a limit per service in excess of which the insured must pay
•may also be an overall annual limit on benefits for all basic services
How are major services, such as oral surgery, root canals, periodontics, bridges, & implants, usually covered?
•may be subject to a higher coinsurance rate, such as 50%, as well as per-service limits
•replacement of dentures may be limited to once every 5 years
•orthodontia usually has its own separate deductible, higher coinsurance rate, & annual limit
What is the predetermination of benefits requirement?
•most dental expense plans recommend (some 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, & 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
What are typically excluded from coverage under dental expense plans?
•cosmetic treatment
•oral hygiene instruction
•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’ comp
•treatment received in government facilities
What happens when a dental expense plan is integrated into a comprehensive health plan?
•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 & coinsurance requirements
What are the 2 main ways dental expense coverage differs from medical coverage?
•patients’ choices in treatment options for dental work often represent a big difference in cost
•needed dental work can often be postponed longer than necessary medical treatment
—>employees who need dental work may be able to wait until a dental expense plan becomes effective, causing the insurer to be liable for larger benefits than it would otherwise expect to pay
What restrictions do insurers often impose to minimize the increased potential for adverse selection in dental expense plans?
•probationary periods
•limitations on benefits for late enrollees
•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, dental expense coverage is subject to COBRA continuation rules)
