What to look for in a good dental benefit plan

Elements of a good dental plan include:

• Affordability: Benefit plans are affordable. Due to the dental profession's promotion of fluoride, sealants and other preventive dental care, oral health in America has improved. The cost of dental treatment has risen less than medical care, physician services and hospital room rates.

• Prevention: Dental disease is most often preventable. Preventive care is especially important since dental disease does not heal itself.

• Cost-effectiveness: If decay or disease is detected, the sooner it is treated, the less costly that treatment will be.

• Predictability: Although the need for dental care varies greatly between individuals, the dental needs of an employee group are highly predictable. For this reason, a dental benefit can be self-funded. The risk of wide fluctuations in cost and utilization, evident in many medical benefits, is rarely observed with dental statistics.

Traditionally, dental benefit plans permit patients to receive treatment from the dentist of their choice. Fee-for-service plans pay the benefit on a service-by-service basis rather than on a salaried or capitation basis. Many time such plans are called UCR (usual, customary, reasonable) plans. The benefit pays on a set percentage of the lesser of the dentist's fee or that fee which has been determined to be "customary" or "reasonable". The insurance company determines what is customary, the percentile on which the payment is based. Frequently it is based on the 90th to 85th percentile. That means, the payer will honor claims in full if they do not exceed the specific percentile. This is fiscal management device that allows payers to limit the dollar consequences of their plans. The patient is responsible for the difference between what the plan pays and the dentist's charge.

Types of services included in a dental benefits plan

Three categories of treatment that are included in a good benefit plan. They are:

• Preventive, Diagnostic and Emergency Services
  Preventive dentistry refers to the dental procedures which prevent the occurrence of oral disease. Diagnostic services are those which detect the presence or absence of disease. Both preventive and diagnostic services are vital to the oral wellness of the public and should be considered an integral part of any company's program. By providing access to these services, employers can realize long run cost containment. Such services include oral examinations, cleanings, X-rays, fluoride applications, sealants and space maintainers. It is recommended by the ADA and WDA that this category of treatment be covered 100% with no deductibles or co-payments.

• Routine Dental Care
  Routine dental care covers a broad range of dental treatments since the routine needs of employees in any company will vary considerably. A dental benefits plan should include, routine restorations, routine oral surgery, routine periodontics and root canal therapy. Coverage for this category of treatment is frequently at 80%.

• Complex Dental Care
  Complex dental care generally involves more involved and/or extensive dental procedures such as dentures, bridges, orthodontics. Coverage for this category of treatment is frequently in the 50% payment range.

How a dental benefit should satisfy your family's needs

Three things to look for to adequately cover your family's needs. At the least, the plan itself should cover the treatments as listed in answer #1 above.

There should be patient participation in the payment through copayments because it is through a personal responsibility of assisting with the payment that one values the benefit. It should be remembered that most dental plans are designed to be of "assistance" in paying for dental services, not a 100% coverage for every procedure needed.

There are additional things to consider when a family is choosing between options of dental benefit plans.

• Will they have to change dentists?

• If they have to choose a dentist from a list of providers, they should consider where the dentist they choose is located.

• Can they choose the dentist to whom they want to go for their care?

• Does the plan allow freedom to choose a specialist?

• Ask friends and neighbors about the plan the family is considering.

The effects of poor oral health on job performance

Negative impact of poor oral health and problems that lead to lost work hours.

Dental disease does not go away. Left without care, it only gets worse. Once decay or disease has begun, professional intervention is necessary to halt its progress. Therefore, it is beneficial to treat problems when they are small instead of letting them go which will result in them becoming more extensive. In addition, as more extensive treatment is needed, it becomes more expensive. For example, a small cavity grows bigger without treatment. It can develop into a large cavity that needs a large restoration. A small cavity may be filled for $45.00 whereas a 3 surface amalgam, (a large filling) may cost twice or three times that amount.

Left without treatment the large cavity becomes so bad that either a root canal needs to be done or the tooth is pulled. In either case, the employee will loose work because the root canal takes several visits to the dentist, and following that, they will probably have to have a crown placed on the tooth. These procedures can easily cost $800 combined. If the tooth is pulled, then the decision will have to be made as to what type of replacement will be made to take up the space left by the removed tooth, (Crown, bridge, etc.) If the space is not filled by putting in a bridge or partial, the teeth on the two sides of the missing tooth can start moving over into the space and cause many problems with biting, shifting teeth, gum disease, etc. Not only do these procedures cost more to correct, more time is expended away from work to have them done.

I need not belabor the point more, but to state again, dental disease does not go away as might a stomachache or sprain. It gets more extensive and expensive. Needing professional intervention, more time and money to treat.

Reasons employers should offer dental benefits

Arguments to encourage an employer to offer dental benefits.

• Dental treatment is relatively low-cost . It makes economic sense to provide a dental benefit package. 

• Dental benefits help individuals by paying for a portion of the cost of their dental care.

• Employee absences or poor work performance may be attributed to poor dental health. According to the National Center for Health Statistics, each year, one out of every ten individuals experience a restricted day, bed day or lost work day due to dental disease.

• Dental benefits can enhance a collective bargaining package. Having a dental benefits plan aids in the recruitment and retention of employees. Dental benefits are consistently cited as one of the most sought after employee benefits. Recent polls also rank dental coverage as one of the top five benefit factors weighed by employees considering job offers.

• There are a variety of dental plans giving plan purchasers the ability to select from a variety of plan models with a range of benefit levels.

• Dental benefit plans promote oral health. History has shown that dental benefits have played an important role in improving access to dental care for millions of Americans.

Direct Reimbursement: A viable alternative to traditional benefit plans

A consumer's perspective of Direct Reimbursement.

What is Direct Reimbursement?
A Direct Reimbursement plan calls for direct reimbursement to employees for any incurred dental expense, or a specified portion thereof, during a plan year, upon presentation of a paid receipt from the treating dentist. Benefits are expressed in maximum dollar limits per year or a percentage thereof, rather than on a list of covered services.

Advantages for the employee

• The employee goes to the dentist of their choice
• The plan is easy to understand.
• The paid receipt is presented to the employer and payment is made according to the pre-arranged percentage of the maximum limit.
• Typically there are no exclusions.
• Prompt reimbursement from the employer.
• Makes the employee a wise dental consumer.

Advantages for the employer

• A larger share of the benefit dollar goes to dental care.
• The middleman, the insurance company, is removed.
• Administrative costs can be reduced from as much as 20-35% of the premium dollars, to below 5%.
• Cost savings.
• Flexibility. The employer can design the plan. The plan can reflect the corporate philosophy.
• Increased employee satisfaction.
• Employer assumes control of the level of benefits.
• Cost is based on actual experience of the plan.
• Investment of funds held in reserve, generating additional income.

Disadvantages
Having surveyed employers that have established Direct Reimbursement plans for their employees, they have testified that there is not a down side to their DR plan. Employers who have instituted DR plans would not dream of discontinuing their plans. They love the simplicity, flexibility and cost effectiveness of their plans.

A consumer's perspective of managed care

• The features and benefits of managed care from a consumers' perspective:
• There are several models of managed care dental benefits plans.
• A Preferred Provider Organization (PPO) is a contracted plan whereby dentists contract to agree to discount their fees, sometimes as much as 20%, as a financial incentive for patients to select their particular practices.

Advantage: 
* Reduced premium rates.

Disadvantage: 
* If the patient's dentist is not a participant in the plan, and the patient decides
   to remain with their dentist, the patient will have a reduced level of benefits.
* The patient will have to change dentists to maintain full level of benefits.
* The plan may influence provider treatment.
* The patient may have to travel a greater distance to obtain treatment from 
   a contracting dentist.

Capitation in another form of managed care. A capitation program pays a contracted dentist a fixed amount per enrolled family or patient per month. In return the dentist agrees to provide a specific level of treatment or scope of benefits to the patients as necessary.

Advantages:
* Generally there is very limited out of pocket expenses.
* The premium is generally the least expensive dental plan to purchasers.
* Benefits are easily understood.

Disadvantages:
* The patient's dentist may not be a participant in the panel of providers. 
   Patient may have to change dentists.
* Patients pay an additional sur charge for some of the more expensive 
   procedures especially those that involve a lab charge.
* There is the uncertainty of not knowing if the payment to the dentist 
   sufficiently covers the amount and level of dental care required.
* Patients are required to obtain treatment from designated clinics or dental
   offices. It is not uncommon that the patient does not see the same dentist 
   every time they go to the dentist.
* Depending on the specific design of the plan, specialty care and referrals 
   may be excluded or severely restricted.

There is some question as to the effect of the capitation model on dentists' treatment decisions since the payment is independent of the rendered care. This potential conflict between the patients' and the dentists' interests could result in undertreatment, pacing of necessary treatment, or other situations leading to friction in the doctor-patient relationship.