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CEBS-GBA 1 Dental Plan Design
Dental Plan Design Notes
34
Insurance
Professional
12/21/2016

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Term
3 Categories of Dental Providers
Definition
1.BCBS organizations and Dental Associations (i.e. Delta)
2.Self-insured, self administered
3. HMO or group practice
Term
3 Dental Plan Design Structures
Definition
1. Fee for service indemnity (reimbursement approach)
2. PPO (the prevailing approach)
3. DHMO
Term
Preferred Dental Provider Benefit Payments
Definition
Most BCBS, dental associations, and insurance companies -- benefits payable directly to treating dentist at fixed reimbursement level by contract
Term
Indemnity Dental Provider Benefit Payments
Definition
expenses are submitted to administrator (usually the insurer) and payment made directly to EE
Term
Differences between indemnity and preferred provider dental plans
Definition
Relate to roles of the provider and covered EE--plan sponsors have great latitude under both
Term
DHMO Dental Provider Benefit Payments
Definition
prepaid, fixed, uniform payment.
Term
Advantages of DHMOs
Definition
Cost, Quality, and Administrative advantages
Term
Disadvantages of DHMOs
Definition
limited provider selection and little latitude in design
Term
Number of Dental Treatment Categories
Definition
10 categories, plus palliative (pain relief) and emergency care and consultation
Term
5 Types of Dental Plans
Definition
1. Scheduled
2. Non-Scheduled
3. Combination
4. Incentive
5. Medical and Dental Combo
Term
Scheduled Dental Plans
Definition
a listing of fixed allowances; may include small or LT deductible; may include coinsurance
Term
Advantages of Scheduled Dental Plans
Definition
Cost control (fixed benefit levels)
Uniform payments
Ease of understanding
Term
Disadvantages of Scheduled Dental Plans
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
Term
Example of Scheduled Dental Plan
Definition
DHMOs
Term
Non-Scheduled Dental Plans
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
Term
Advantages of Non-Scheduled Dental Plans
Definition
Uniform reimbursement (% of total cost rather than set $); adjusts automatically for change
Term
Disadvantages of Non-Scheduled Dental Plans
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
Term
Example of Non-Scheduled Dental Plans
Definition
PPOs (charges are based on agreed upon discount vs. R&C)
Term
Combination Dental Plans
Definition
aka Hybrid; some procedures on scheduled basis while others on non-scheduled basis
Term
Advantages of Combination Dental Plans
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
Term
Disadvantages of Combination Dental Plans
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
Term
Incentive Dental Plans
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
Term
Advantages of Incentive Dental Plans
Definition
Encourage regular dental care; have lower first year costs than most nonscheduled plans
Term
Disadvantages of Incentive Dental Plans
Definition
Can be complicated to understand; little evidence it promotes dental hygiene; vulnerable to misunderstanding
Term
Orthodontic Expenses
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
Term
Implantology
Definition
often excluded; inclusion is a cost-driven plan design decision; once a lifetime so LTM and LT deductible; coinsurance same as for ortho
Term
Factors affecting cost of dental plans
Definition
Plan Design; Group Characteristics; ERs approach to implementation; plan administration
Term
Group Characteristics used in Dental Plan Design and Cost
Definition
Age; Gender; Location; Income; Occupation
(Older ages have higher costs)
Term
Disadvantage of advance notice of Dental Plan Effective Date
Definition
can lead to sandbagging--deferral of care until after the plan's effective date
Term
Effects of Sandbagging
Definition
Poor first year experience--advanced knowledge can increase first year costs from 10-20%
Term
Safeguards against adverse selection in dental plans
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
Term
HIPAA and dental plans
Definition
HIPAA doesn't apply as long as dental benefits are limited in scope and available under a separate rider or policy from medical
Term
Most important consideration in selecting a dental carrier
Definition
Claims administration capabilities
Term
One key element to effective dental plan administration
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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