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.
……..(Go To Part 2)
Advantages of Offering a Dental Benefits Plan to Employees
(Part 2 of 3)
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. ……..(Go To Part 3)
Advantages of Offering a Dental Benefits Plan to Employees
(Part 2 of 3)
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.
No comments:
Post a Comment