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12 Cards in this Set
- Front
- Back
Differences between Dental and Medical Plans
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Dental Plans focus on preventive care
Dental claim costs are lower. Deductibles lower. Dental service is elective, so only group coverage is offered. Dental plans are designed to reduce antiselection. $1000 Lifetime Max, whereas Medical is unlimited. No conversions to individual policies Experience Rating is used more often because claim costs lower, in a narrower range, and more credible |
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Dental benefit classes
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Type I (Preventive and Diagnostic)
Type II (Basic) Type III (Major) Orthodontics has its own ded and maximum covg only 25% of orthodontic costs are covered, due to elective nature. A 100/80/50 plan reimbs 100% of Type I, 80% of Type II, and 50% of Type III. |
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UNDERWRITING FEATURES FOR GROUP DENTAL INSURANCE
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A S H F I L E O A F F E Z P O T
A (age), S (sex), and F (family) Only actives and their dependents + spouses are covered. Old; females utilize more I (industry) Actors, Teachers, Professionals, and Sports Teams utilize most L (location) costs in cities are higher O (offsetting, coordination) A (antisel ctrls) Min. Ee participation level; Min. Er contribution see below for more Z (group Size) should be > 5 larger lower costs per member (less antiselection) P (prior coverage) groups with no prior coverage high costs due to antiselection. long pre-announcement period same. O (overstaffedness, turnover) means constant new antiselection. T (type of group) Must not be formed for the purpose of getting insurance. |
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TYPES OF DENTAL DELIVERY SYSTEMS
Indemnity Plan |
Scheduled Indemity Plan
There’s a list of covered services (ADA #’s) Each has its own maximum reimbursement Dentists paid FFS Dentist can balance-bill. Disadvantage The schedule of maximum benefits must be updated each year. Non-scheduled Indemnity Plan Most common. Reimburses the patient based on the UCR cost of any procedure (still subject to the plan’s deductibles and coinsurance) |
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Managed Indemnity Plan
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Ins Cpy negotiates lower Ffs’s with network dentists.
patients are encouraged to use the network dentists (by reduced charges). Advantage: introduces the Managed Care concept to employees |
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PPO Plan
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providers accept discount from Ffs in return for a higher volume of patients
patients given incentives to use in-network providers: richer benefits no balance-billing. Discounted Fee for Service PPO Fee Schedule PPO Fewer dentists will agree to this. Discount Referral Plan Not an insurance plan. Ee simply receives a discount on dental work from participating dentists. The patient pays the dentist directly. Exclusive Provider Plan (EPO) An in-network only dental plan. Better discounts can be negotiated. PPO’s provide many of the same functions as regular HMO's: Claims adjudications Financial reporting UR, CM, QM |
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POS Plan
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Patient can pick an HMO provider or an out-of-network provider
out-of-network benefits are lowest. |
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Dental HMO (DHMO) Plan
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No deductible; No benefit maximums
Benefits are richest out of all the dental plan types. there are Copays. Type III procedures may have coinsurance. IPA Model DHMO dental orgz’s receive capitation payments specialty dentists still paid Ffs. Staff model DHMO dentists paid a monthly salary gives HMO most control over cost of care |
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COMPARISION OF THE TYPES OF DENTAL DELIVERY SYSTEMS
PPO is in the middle, for each category. |
HMO PPO Indemnity
Price low high Benefit Richness high low Preventive care high low Access low high Cost Control highest lowest Quality Assurance high low Fraud Potential lowest highest |
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CREDENTIALING OF DENTISTS
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every few years
Screened credentials: Biographical info Practice info malpractice history office reviews patient records |
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ANTISELECTION CONTROLS FOR DENTAL INSURANCE
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include out-of-pocket costs
cover only 25% of orthodontics use lifetime maximums underwrite by age, family, insustry, group size, group type require employer contribution minimum ee participation % package Dental with other coverages waiting period Or tiered coinsurance new and late entrant deferral periods exclusions (missing tooth, cosmetics, experimental) |
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COST CONTROLS USED IN DENTAL INSURANCE
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All of the Antiselection Controls (above)
Incentive Coinsurance (discounts build if patient gets preventive treatment) UCR LEAT Frequency and Age restrictions precertification / authorization proof of medical necessity Dental Review Logic & Claim Payment Logic Peer Review Done. |