A Dental insurance or dental benefit plan is viewed upon as a much sought after employee benefit. So financially it makes sense to have a dental benefit plan in place to recruit and retain employees. Moreover, dental health is a very important part of overall employee health and man days lost due to dental problems or dental discomfort of an employee equates to financial loss for the employer.
Unlike most medical conditions, dental maladies and treatments are low risk, predictable and low cost. These factors contribute to offering dental insurance to employees a good option financially. Dental diseases are preventable by maintenance and often involve only maintenance costs like x-rays and examinations. Treatment is rendered cheap due to diagnosis in early stages of the disease. Keeping these financial factors in mind, dental insurance options can also be self funded. History does not show any extremes in costs or utilization of this form of employee benefit.
Selecting the right Dental Insurance Plan
Selecting the right dental plan involves a lot of factors which have to be considered with due care.
Dental insurance plans are basically agreements between the employer and the insurance company. Most plans offered by dental insurance companies allow for part reimbursement of dental treatment expenses. Many plans also discourage certain kind of treatments or allow access to certain of dentists. To consider these points one has to go through the plan very carefully with a toothcomb. For example choosing a dentist is not same as choosing a dentist from “the list”, or if the plan does not cover one kind of treatment, it is wrong to infer that your regular dentist is incompetent.
Many plans do not cover pre existing conditions. Some may not cover implants and so on. Due to these preconditions, the final treatment may be paid for in part only or in insurance parlance you might be reimbursed for LEAT (Lease Expensive Alternative Treatment). Dental insurance plans vary in fixing the UCR (usual, customary, and reasonable) in a certain geographical area. UCR may vary from plan to plan and company to company despite operating in the same area. Therefore fixation of this UCR level would define the liability of the patient. In some plans the patient may have to pay more and in some he may have to pay less depends upon the plan the employer has offered.
Important factors while finalizing on a Dental Insurance Plan
An employee has to ask himself the following before he finalizes on a plan:
Would the employees like to retain the freedom of choosing their own dentists?
Will the mode of treatment be determined by the patient and the dentist?
What type of routine and preventive dental care is covered? Does the plan cover braces, oral surgery, crowns and bridges, root canals and treatment of periodontal diseases?
Will the plan cover all diagnostic, preventive and emergency services? Including preventive services viz. sealants & fluoride treatments, which might result in financial savings to the patient in future? Does it provide for full-mouth x-rays?
What forms of major dental care is covered? Does the plan cover implants, dentures, or treatment for temporomandibular disorders?
Does the plan allow for specialist referrals? If so, has the dentist be limited to “the” list of specialists to choose form?
Does the plan provide for emergencies? What are the provisions made for emergency care when the patient is on tour?
What percentage of monthly premiums goes into actual care and not to administration?
Dental Insurance benefit coverage should be taken into consideration but should not be the deciding factor in choosing the treatment.
Dental Insurance Plan Models
There are numerous dental plans available. Basically they are of two kinds:
Managed care and Fee-for-service.
Managed care dental plans are restricted forms of dental insurance which aim at reducing costs and payouts. They tend to restrict the coverage by limiting the access to care by restrictions (by predefining dentist, specialist, hospital or treatments in form of lists) and restricting level, type and frequency of treatment (usually in form of clauses in the coverage policy).
Fee-for-service dental plans have a freedom of choice options where one can choose their own dentist and the fee is paid as fixed by the dentist.
Kinds of Dental Insurance Plans
Managed Care Dental Plans
Preferred Provider Organization (PPO) plans are plans in which the patient has to select a dentist from a list provided to him. These dentists have agreed to discount their fee by contract with the insurance company. Some PPO plans also allow patients treated by dentists outside their list, where the patient is penalized by excess co-payments and higher deductibles. PPO’s are normally less expensive than indemnity plans in their class.
Keep the following in mind while reviewing a PPO Dental Insurance Plan.
What is the percentage of the premium used for administration?
Will the discount influence patients to change their regular dentist? Will the amount of the discount the dentist ahs to offer affect the number of treatment options for the patient?
What is the liability of the employer in the event of the plan influencing dentist selection or treatment?
What are the criteria of selection of dentists for the plan? Does it have adequate number of dentists under contract? What is the geographic distribution of dentists? Does the PPO dental insurance plan provide for specialist referrals? If so, are the dentists limited to a specialist on the “list” only?
How does the plan provide for emergency treatment? If so then how does the plan provide for emergencies outside the geographical area?
Dental Health Maintenance Organization (DHMO) or Capitation plans are designed in such a way that the patient does not have any financial payout when he goes for treatment. These plans pay the dentists on their “list” a fixed amount of money monthly per enrolled family or individual, regardless of visits. In return, the dentists provides specific types of treatment to the patients who visit him at no charge, any other types of treatments require co-payment. This way, the DHMO is rewarding dentists to keep patients in good health, thereby keeping the costs low. This kind of plan is one of the least expensive.
Factors to consider while reviewing a DHMO plan.
What is the percentage of the premium used for administration?
Does the employer have access to enough information for him to determine the level and amount of treatment rendered to each of the employees?
What is the utilization percentage for patients in this plan? Average waiting period for an initial appointment and average period between appointments has to be given due consideration.
What is the dentist/patient ratio for the DHMO plan? What is the criterion of dentist selection in the program? What is the geographic distribution of dentists?
What percentage of dentists is selected for from those who applied to participate? How many dentists withdrew from the program in the recent past?
What is the rate of compensation for the dentists? Is it sufficient compensation for the needs of the covered patient population? What are the provisions made for dentists in the event of unforeseen utilization?
What are the benefits for patients needing a specialist’s care? How are specialists selected and compensated? Does the plan have adequate specialists?
Does the program provide for any emergency treatment? If so, is it available outside the geographical area?
Fee-for-Service Dental Plans
Direct Reimbursement (DR) plan is a self-funded dental insurance benefit plan which reimburses patients on actual spent on dental care. It is not based on the type of treatment received. The patient has complete freedom in choosing the dentist. The employers are liable to pay a percentage of actual treatment cost, but they do not have to pay monthly premiums for employees who do not need the benefit. Moreover the employer is free of any responsibility to take decisions on mode of treatment due to previous plan selection or sponsorships. Direct Reimbursement Dental Insurance Plan is American Dental Association’s preferred method of dental coverage.