Flashcards in Dental Benefits Deck (42)
8 basic differences between medicine and dentistry
1. Dentists practice in individual offices, isolation tends to produce a greater variety of dental practice patterns
2. Individuals routinely visit their dentists for preventative care
3. Because of prevention, dental treatment is considered elective and postponed unless there is pain
4. Patient has option to defer treatment or not have it at all
5. Dental care often is cosmetic
6. Dentistry often offers a variety of alternative procedures
7. Dental expenses are generally lower, more predictable, and budgetable
8. Preventative care may be more productive in dentistry than in medicine.
Is dental coverage an essential benefit for adults under the ACA?
No, however it is an essential health benefit (EHB) that must be made available by those individual policies and group plans subject to the EHB provisions of the health care reform law.
What organizations provide dental care coverages?
Blue Cross and Blue Shield associations
Others - including state dental assoc. plans (delta plan), self insured, self-administered plans, and group practice or HMO type plans.
What is the breakdown of coverage population
Delta plans - Over 31%
MetLife (insurance company) - 12%
BCBS - < %12
All other carriers less than 10%
Discuss how dental plans resemble today's medical plans - 3 basic approaches
1. Fee-for-service indemnity approach
2. Preferred provider organization approach
3. Dental heath maintenance organization approach
10 professional treatment categories into which virtually all dental problems are places
6. Oral Surgery
Routine oral exam and x-rays
Preserve and maintain dental health
Repair and reconstruction of natural teeth
Treatment of dental-pulp disease and therapy such as root canals
treatment of the gums and other supporting structures such as curettage and root planning
tooth extraction and other surgery of the mouth and jaw
Construction, repair and replacement of missing teeth, crowns, and bridges
Correction of malocclusion and abnormal tooth position
treatment of children who do not have all their permanent teeth
use of implants and related services such as overdentures, fixed prostheses attached to implants and the like to replace one of all missing teeth on an arch
What is palliative treatment
Procedures to minimize pain, including anesthesia, emergency care and consultation
Identify the general groupings of dental procedures that are used in the design of dental plans
1. Preventative and diagnostic procedures
2. Minor restorative procedures
3. Major restorative work, endodontic and periodontic services
4. Orthodontic expenses
5. Today's typical plans often exclude implantology services because of the expense involved
How does a schedule plan operate
Pay fixed allowance for each procedure.
Plan might pay $50 for a cleaning and $400 for root canal therapy
May include deductibles-coinsurance provisions are rare
Advantages of scheduled plans
Ease in understanding the plan
Employee relations reasons related to employee appreciation of the plan
Disadvantages of schedule plans
Benefit levels must be examined periodically to maintain reimbursement objectives
Plan reimbursement levels will vary in different locations according to cost of dental care in that area
If scheduled benefits are set near the maximum of reasonable and customary range, dentists who usually charge less than the prevailing rates mat be influenced to adjust their charges upward.
Describe the operation of nonscheduled dental plans
*Most common of plan offerings
Cover some percentage of the reasonable and customary charges (or charges most commonly made by dentists in the community)
Usual customary charge typically is set between the 75th and 90th percentile, with rend being toward the lower number
Nonschedule plans generally include deductible, typically calendar year of $50 or $75
Prevent and diagnostic expense typically are covered either in full or at a very high reimbursement level
Advantages or nonscheduled dental plan
Percentage of total cost reimbursed by the plan is uniform
Built in auto adjustment for inflation and also for variations in the relative value of specific procedures
Disadvantage of nonscheduled dental plan
Cost control can be a problem because benefit levels adjust automatically for increases in the cost of care in periods of rapidly escalating prices
Once a plan is installed on a nonscheduled basis, opportunities for modest benefit improvements, are limited
Rarely is clear in advance what the specific payment of a particular service will be either to the patent or dentist
What is a combination dental plan
Certain procedures are reimbursed on a scheduled basis while other are reimbursed on a nonscheduled basis. Seek to provide a balance between the need to emphasize preventative care and cost control.
Incentive dental plan
Attempts to promote, or incent, sound dental hygiene through increasing reimbursement levels.
Designed to encourage individuals to visit dentist regularly
Generally reimburse at one level during the first year, with coinsurance levels typically increasing from year to year only for those who obtained needed treatment in prior years
One approach may be to carry over part or all of any unused annual benefit maximums info future periods
Are incentive plans characterized by deductibles?
Not unusual for them to apply on a lifetime basis
Identify and describe the several design peculiarities or orthodontic benefits within dental plans
Almost never written without other dental coverage.
Generally rendered only once in an individuals lifetime
Maximums are typically expressed on lifetime basis
Many plans limit to under 19, however a number of plans include adult orthodontics
Common coinsurance level is 50%, varies widely.
Often paid for in installments
What are the three factors that affect the cost of a dental plan
1. Design of the plan
2. Characteristics of the covered group
3. Employer's approach to plan implementation