Week 4 PP Flashcards
Different forms of Dental Insurance Plans
-Traditional dental insurane plan (employer plan)
-Managed care dental insurance plan (individual plan)
-Government programs
Traditional Insurance Plan / Idemnity Plan
A plan that helps with the cost of dental care.
Considered “fee for service” and come with limitations and co-payment options.
The patient has an annual limit on coverage for dental spending and specific coverage limits that may apply to specific procedures.
Managed Care Dental Plan
-Method of providing low to medium coverage to everyone
-The type, level and frequency of treatment can be limited
-Disease prevention is encouraged
-Plan could also control the level of reimbursement for services
Preferred Provider Oganizations (Dental PPOs)
Tehcnically a closed panel type of plan
- Closed network plan where individuals must visit a preselected or assigned network dentist to receive benefits
- A dentist may join a PPO in hopes of attracting new patients
-Patients are charged the dentist’s usual fees
-SAIT’s student dental plan is like this. Students can see a preferred provider or a dentist of their choice
Dental Benefits Maximum = $750 per her 80 % basic coverage
Exclusive Provider Organizations (EPOs)
- Form of closed panel dental insurance
- Patient’s are offered NO option other than receiving their treatment from a dentist who is a member of the plan’s network of providers
- University of Calgary student insurance
- Maximum of $750 per year
- Note that these benefits can only be used at Dental Choice clinics in Alberta (6 offices in
Calgary). Services performed at other dental centers will not be eligible for reimbursement.
Direct Reimbusement Plan
- Self-funded program
- Individual is reimbursed by their employer based on a % of dollars spent for the dental care provided.
- Can seek treatment from the dentist of their choice.
- No insurance company involved.
- Employee pays the dentist and the employer reimburses the employee a portion of the
expense. - Amount reimbursed is decided by the benefit design established by the employer.
Basic Procedure Coverage
Benefits covered to maintain and preserve the oral structure. Procedures covered may vary, but commonly include..
✓ Prophylaxis
✓ Scaling
✓ Fluoride (usually has age restriction)
✓ Restorations
✓ Extractions
✓ Root Canals
✓ Radiographs
✓ Study Models
✓ Biopsies
This is usually the area with the higher percentage of coverage. Most common is 80% or 100% coverage of the dental insurance company’s fee guide.
What is Major Coverage?
These are benefits for more extensive treatment. Procedures covered may vary, but commonly include:
✓ Crown
✓ Bridge
✓ Dentures
✓ Complex Oral Surgery
✓ Periodontal treatment (surgeries)
These procedures are usually covered at a lower percentage of coverage. Most common is 50% coverage of the insurance company’s fee guide.
What is the subscriber?
The person who carries the insurance and also the person receiving the treatment
What is a Dependent?
child or spouse of the subcriber
Who is the Carrier?
The insurace company who pays the claims and collects premiums
Who is the Group?
The employer that purchased or arranged insurance as a benefit
Who is the Provider?
The dentist or hygienist who performs the service
3 Most Common Methods of Calculating Fee-For-Service Benefits
- Usual, Customary & Reasonable (UCR Fees)
- Schedule of Benefits
- Fixed Fee Schedule
UCR Fees
Usual: Refers to the fee that the dentist charges private patients for a given service. Fees are determined by the dentist and are the fees routinely charged by the practice. A dentist will confidentially file their fees with dental insurance companies. This information (prefiled fees) is sued by the insurance company to establish the customary fees for the area.
Customary: fee that is within the usual range of fees charged for the same service by similary trained dentists in the same geographical area. Established by comparing pre-filed fees of dentists in the area.
Reasonable: fee that is considered justified by special circumstances necessitating complex treatment (where dentist charges more than the usual fee wheven to a private patient). An example would be a complicated extraction. Dentist would need to submit written documentation explaining why the unusual fee is required.
In an UCR system the patient is responsible for…
the difference between the insurance payment and the dentist’s fees
- limitations of the policy will influence the amount the dentist receives from the carrier and the amount the patient must pay
Limitations and exlusions
Dental plans do not usually cover all procedures
Each plan contains a list of conditions or circumstances that limit (number of procedures permitted udring a time period; 1 cleaning per 6 months) or exludes services from coverage (no orthodontic treatment)
Table of Allowance/ Schedule of Allowances:
-List of fixed amounts that the carrier will pay towards the cost of covered services
-Is not related to the dentist’s actual fee schedule
-Created by the insurance company (Eg. blue cross has its own fee guide)
Patient is responsible for the difference between what hte Carrier will pay and what the dentist charges
What is a Fixed Fee Schedule?
An established fee for any treatment received by the patient.
- Often lower than average fees
This is used for Government Plans - (Alberta Child Health Benefit, AISH, Non-Insured Health Benefit - includes all registered First Nations & Inuit persons)
Dentist must accept this fee and cannot bill the patient the difference
*Some programs eligibility can change month to month so verification of coverage must be done frequently
Determining Eligibility
When an employee starts a new job there is typically a waiting period before benefits become effective (employee pays into the benefits for a specified period of time)
If an employee retires, quits, or is laid off the insurance coverage will typically terminate within 30 days of the change
Determining Benefits
The employer purchases benefits for their employees and negotiates the limitations and benefits of the plan
The insurance company is only responsible for covering the level of treatment outlined in the employer’s plan
This information can be found in the benefits booklet
If possible, the patient should bring their booklet to their first appointment or review it online prior to dental treatment
Dental Insurance Limitations
-There are several factors that influence the level of benefits that the beneficiary is eligible for and the amounts they must pay as a share of these costs
Least Expensive Alternative Treatment - LEAT
This is a limitation in a dental plan that allows for benefits only for the least expensive treatment.
For Ex: a patient needs to replace a missing tooth
Treatment options: Fixed bridge for $4000 or partial denture for $2500
Under LEAT the carrier will pay the benefits for a partial denture only. If the patient decides on the fixed bridge, the patient MUST pay the difference in cost
Dual Coverage
-Patient has dental insurance coverage under more than one plan
-Steps to make sure the benefits are paid
