VIII. Dental Insurance Flashcards
Define Prosthodontics.
Replacement of missing teeth with artificial devices like bridgework or dentures
Describe the difference between scheduled and nonscheduled plans.
Scheduled: pay first dollar without coinsurance or deductible. Pay benefits from a list of procedures. Max benefits are lower.
NonScheduled: benefits are paid on a reasonable and customary basis and are subject to deductible and coinsurance. Services are usually divided into three broad benefit categories: Diagnostic/ preventative services, basic services, and major services.
Describe the difference between basic and major dental services.
Basic: Fillings, oral surgery, periodontics, and endodontics may require the insured to pay a deductible or 20% of the balance.
Major: inlays, crowns, dentures, orthodontics. large deductibles or pay 50%.
List 3 things that are commonly excluded from dental plans.
cosmetic services (unless required by an accident), replacement of lost dentures, occupational injuries covered by workers comp.
In dental coverage, how many visits is the limit for preventive care?
Cleanings 1 every 6 months, full mouth x-rays to once every 2 to 3 years, and replacement of dentures to once every 5 years.
To prevent adverse selections, late enrollees for dental insurance may get what type of benefits?
Reduced benefits for first year.
What limitations are posed on denture replacements?
Once every 5 years
Under which plan does preventative dental treatment not apply toward the deductible?
Under nonscheduled plans, routine examinations and preventative care generally do not apply toward the deductible.
Combination plans are comprised of two types of plan features:
Combination plans combine features of the two main types of dental plans: scheduled (basic) and nonscheduled (comprehensive). The combination plan covers diagnostic and preventive services on the usual, customary and reasonable basis but uses a fee schedule for other dental services.
What is a Comprehensive plan?
Comprehensive plans provide coverage on a usual, customary and reasonable basis, and are similar in operation to major medical expense policies. A flat annual deductible is applicable to covered dental expenses with specific procedures subject to coinsurance provisions.
Pete has dental coverage provided under a Comprehensive (nonscheduled) Dental Plan. Diagnostic or Preventive Care would not require a deductible or copayment
Basic or scheduled plan.
A dental plan that provides coverage based upon a specified maximum scheduled amount for each procedure and pays on a ‘first dollar’ basis with no deductible or coinsurance. The basic or scheduled dental plan pays a scheduled amount which is typically below usual, customary and reasonable dental charges, causing the employees to bear a share of the cost of the procedure.
Following hospitalization because of an accident, Bill was confined in a skilled nursing facility. Medicare will pay full benefits in this facility for how many days?
Following hospitalization for at least three days, if medically necessary, Medicare pays for all covered services during the first 20 days in a skilled nursing facility. Days 21 through 100 require a daily copayment.
A person buys an individual long-term care policy and is not satisfied with the provisions. Within how many days will the insured be able to return the policy for a full premium refund?
Individual long-term care insurance policyholders and group certificate holders who contribute to the cost of their long-term care coverage have the right to return the policy within 30 days of its delivery and have the premium refunded if, after examining the policy or certificate, they are not satisfied for any reason.
