Dental Insurance

What are the types of dental treatment?

• diagnostic & preventive = routine exams, x-rays, cleaning

• restorative = repair or restore teeth; fillings & crowns

• oral surgery = surgery for cavity; wisdom teeth

• endodontics = center of tooth, like root canal

• periodontics = treatment for the gums

• prosthodontics = artificial replacements, like bridges and implants

• orthodontics = braces

Which type of plan is most common for dental insurance?

PPO

Scheduled vs Nonscheduled plans

Scheduled = benefits limited to a specified maximum per procedure w/ 1st dollar coverage; like basic hospital and medical.

Nonscheduled = most common that pay to n a usual, customary, and reasonable (UCR), but use a fee schedule for other dental services.

Deductibles, Coinsurance, and Limits

Deductibles, Coinsurance, and Limits apply differently depending on the treatment.

• diagnostic/preventive = no deductible or coinsurance

• basic services (fillings, crowns, local anesthesia) = yes deductible and 20% coinsurance

• major services (oral surgery, root canal, bridges, implant, periodontics) = 50% coinsurance and per-service limits

• orthodontics = separate deductible, higher coinsurance, annual limit

What is Predetermination of Benefits?

Often required, a written treatment plan showing charges for each service, and breakdown of what is covered and what is out of pocket.

What are common exclusions?

• cosmetic

• replacement of teeth missing before coverage

• loss of dentures

• occupational injuries

Employer Group Dental plans

Integrated = included in a comprehensive health plan. Does not have a separate deductible, only health plan deductible.

stand alone = most common w/ its own deductible and coinsurance

What can insurers do to minimize adverse selection?

• probationary periods = waiting period after eligibility before coverage is effective.

• limitations = limitations on benefits for late enrollees.

• reduced benefits = reduced benefit limits during the 1st year of coverage.