week 3 Flashcards
What are the major entities involved in the financing of dental care today ?
Financing dental care involves patients, dental practitioners, and several other entities, including public programs and insurance companies.
What significant act was created in 1965 that impacted dental care funding?
The Social Security Act of 1965, which established public funding like Medicaid.
When was insurance for dental care first introduced, and when did it become widely accepted?
Dental insurance began in the early 1900s but was not widely accepted until the 1970s.
What percentage of U.S. health care expenditures was spent on dental services in 2020?
Only 3% of health care expenditures were spent on dental services, and 86% of this amount was from private funds.
What dental coverage requirements exist for Medicaid regarding children?
States are required to offer Medicaid dental coverage to children from low-income families, though coverage for adults varies by state.
What are the four types of payment methods in dental care?
Fee-for-service, capitation plans, encounter fee plans, and barter system.
What is a capitation plan?
A dental provider contracts to provide most services to subscribers in return for a per capita payment, typically on a monthly or yearly basis.
What are the two main types of private dental insurance?
Fee-for-service, PPOs and HMOs.
What is a characteristic of PPO dental plans?
PPOs offer lower costs for services within a network but restrict patient choice.
What are the two forms of payment in an indemnity plan?
The dental provider bills the patient, and the patient seeks reimbursement, or the provider bills the insurance, and the patient pays any difference.
What are direct payments in dental care?
Payments made by patients for services not covered by insurance, including copayments, deductibles, and coinsurance.
What responsibilities do dental hygienists have regarding insurance codes?
Dental hygienists are legally responsible for choosing the correct codes for services provided and must maintain accurate documentation.
Why is financing a critical factor in accessing dental care?
Financing affects the availability and quality of dental care. Historically, financing was the responsibility of the patient and dental practitioner, but now it involves insurance companies and public funding.
What major public funding program was created in 1965, and who does it serve?
Medicaid was created by the Social Security Act in 1965. It serves patients who meet disability requirements, with dental coverage for children from low-income families and, in some states, adults.
What are the four types of payment methods in dental care?
The four types are Fee-for-Service, Capitation Plans, Encounter Fee Plans, and the Barter System.
How does a fee-for-service plan work?
A fee-for-service plan is based on a fee scale for all covered services. The patient or the insurance company pays the fee for the services rendered. A sliding fee scale is available for lower-income patients.
What is a capitation plan in dental care?
In a capitation plan, a dental provider contracts with a program to provide all or most dental services to subscribers in return for a per capita payment, often monthly or yearly.
How does the encounter fee plan differ from fee-for-service?
In an encounter fee plan, payment is based on an office visit, and the fee remains the same regardless of the services provided.
What is the barter system in dental care payment?
The barter system involves the dental provider and the patient negotiating payment by exchanging goods or services, without using money.
What is the difference between PPOs and HMOs in dental insurance?
PPOs offer lower costs for in-network services but limit provider choice, while HMOs focus on preventive care and also limit provider options, emphasizing cost control through managed care organizations (established in 1973 by the HMO Act).
How does an indemnity insurance plan work in dental care?
An indemnity plan operates through a submission and reimbursement method, where the dental provider bills the patient and the patient seeks reimbursement from the insurance company. Providers may offer discounts to target populations.
What are direct payments in dental care, and what are some examples?
Direct payments are costs patients pay for services not covered by insurance, including copayments, deductibles, and coinsurance.
What are some cost barriers to dental care?
High costs can deter individuals from seeking necessary care, particularly when out-of-pocket expenses are high or insurance coverage is limited.
What is insurance fraud in dental care, and how can it occur?
Insurance fraud occurs when incorrect codes are entered to falsely obtain payment. It can happen by entering a false date of service or coding for a procedure that was not performed. Dental hygienists are responsible for selecting the correct codes and maintaining documentation.
