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Flashcards in Dental Benefits Deck (42)
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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?

Insurance Companies

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

1. Diagnostic
2. Preventative
3. Restorative
4. Endodontics
5. Periodontics
6. Oral Surgery
7. Prosthodontics
8. Orthodontics
9. Pedodontics
10. Implantology



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


Oral Surgery

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

Cost Control
Uniform payments
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


What are the issues to be addressed in designed a dental plan

Type of plan
Plan Maximums
Treatment of preexisting conditions
Whether covered services should be limited and the questions concerning orthodontic coverage