Term
| 3 Categories of Dental Providers |
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Definition
1.BCBS organizations and Dental Associations (i.e. Delta)
2.Self-insured, self administered
3. HMO or group practice |
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Term
| 3 Dental Plan Design Structures |
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Definition
1. Fee for service indemnity (reimbursement approach)
2. PPO (the prevailing approach)
3. DHMO |
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Term
| Preferred Dental Provider Benefit Payments |
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Definition
| Most BCBS, dental associations, and insurance companies -- benefits payable directly to treating dentist at fixed reimbursement level by contract |
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Term
| Indemnity Dental Provider Benefit Payments |
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Definition
| expenses are submitted to administrator (usually the insurer) and payment made directly to EE |
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Term
| Differences between indemnity and preferred provider dental plans |
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Definition
| Relate to roles of the provider and covered EE--plan sponsors have great latitude under both |
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Term
| DHMO Dental Provider Benefit Payments |
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Definition
| prepaid, fixed, uniform payment. |
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Term
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Definition
| Cost, Quality, and Administrative advantages |
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Term
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Definition
| limited provider selection and little latitude in design |
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Term
| Number of Dental Treatment Categories |
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Definition
| 10 categories, plus palliative (pain relief) and emergency care and consultation |
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Term
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Definition
1. Scheduled
2. Non-Scheduled
3. Combination
4. Incentive
5. Medical and Dental Combo |
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Term
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Definition
| a listing of fixed allowances; may include small or LT deductible; may include coinsurance |
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Term
| Advantages of Scheduled Dental Plans |
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Definition
Cost control (fixed benefit levels)
Uniform payments
Ease of understanding |
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Term
| Disadvantages of Scheduled Dental Plans |
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Definition
| Benefit levels must be reevaluated periodically; reimbursement levels vary based on geographical cost of care; if near max R&C, dentists may increase normal rates |
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Term
| Example of Scheduled Dental Plan |
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Definition
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Term
| Non-Scheduled Dental Plans |
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Definition
| aka Comprehensive (most common type; cover 75-90% of R&C; include CY deductible ($50 or $75); reimburse at varying levels based on class of procedure; preventive and diag. usually covered in full |
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Term
| Advantages of Non-Scheduled Dental Plans |
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Definition
| Uniform reimbursement (% of total cost rather than set $); adjusts automatically for change |
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Term
| Disadvantages of Non-Scheduled Dental Plans |
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Definition
| Cost control--auto adjustment of benefit levels can cause extreme increases in cost of care; limited ability to improve benefits; costs are not clear in advance |
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Term
| Example of Non-Scheduled Dental Plans |
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Definition
| PPOs (charges are based on agreed upon discount vs. R&C) |
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Term
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Definition
| aka Hybrid; some procedures on scheduled basis while others on non-scheduled basis |
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Term
| Advantages of Combination Dental Plans |
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Definition
| Balanced between need for preventive care and need for cost control; expensive procedures on scheduled basis; ER decides when to make schedule changes; preventive and diag. adjust automatically so no loss in effectiveness |
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Term
| Disadvantages of Combination Dental Plans |
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Definition
| Benefits above preventive and diagnostic need evaluation periodically; scheduled payments no uniform for geographically disbursed EEs; dentists may increase rates; expenses rarely known in advance |
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Term
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Definition
| increasing reimbursement levels; generally only apply to preventive and maintenance; reimburse at one level during first year and goes up in next years; sometimes have LT deductible |
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Term
| Advantages of Incentive Dental Plans |
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Definition
| Encourage regular dental care; have lower first year costs than most nonscheduled plans |
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Term
| Disadvantages of Incentive Dental Plans |
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Definition
| Can be complicated to understand; little evidence it promotes dental hygiene; vulnerable to misunderstanding |
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Term
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Definition
| never written w/o other dental coverage; LTM due to once a lifetime use; no deductible; can be limited to children only; typically 50% coinsurance; often paid in installments |
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Term
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Definition
| often excluded; inclusion is a cost-driven plan design decision; once a lifetime so LTM and LT deductible; coinsurance same as for ortho |
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Term
| Factors affecting cost of dental plans |
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Definition
| Plan Design; Group Characteristics; ERs approach to implementation; plan administration |
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Term
| Group Characteristics used in Dental Plan Design and Cost |
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Definition
Age; Gender; Location; Income; Occupation
(Older ages have higher costs) |
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Term
| Disadvantage of advance notice of Dental Plan Effective Date |
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Definition
| can lead to sandbagging--deferral of care until after the plan's effective date |
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Term
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Definition
| Poor first year experience--advanced knowledge can increase first year costs from 10-20% |
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Term
| Safeguards against adverse selection in dental plans |
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Definition
| combining plan participation and contributions with medical plan contributions; limiting enrollment to one chance; requiring dental exams before joining the plan; req. participation for set time before able to drop coverage |
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Term
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Definition
| HIPAA doesn't apply as long as dental benefits are limited in scope and available under a separate rider or policy from medical |
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Term
| Most important consideration in selecting a dental carrier |
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Definition
| Claims administration capabilities |
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Term
| One key element to effective dental plan administration |
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Definition
| Predetermination of benefits (only in non-emergencies and more than $300 in expected costs)--this can reduce claims by 5% |
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