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12 Cards in this Set

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Differences between Dental and Medical Plans
 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
Dental benefit classes
 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.
UNDERWRITING FEATURES FOR GROUP DENTAL INSURANCE
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.
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)
Managed Indemnity Plan
 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
PPO Plan
 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
POS Plan
 Patient can pick an HMO provider or an out-of-network provider
 out-of-network benefits are lowest.
Dental HMO (DHMO) Plan
 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
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
CREDENTIALING OF DENTISTS
 every few years
Screened credentials:
 Biographical info
 Practice info
 malpractice history
 office reviews
 patient records
ANTISELECTION CONTROLS FOR DENTAL INSURANCE
 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)
COST CONTROLS USED IN DENTAL INSURANCE
 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.