Posted January 12, 2012
At first glance, dental insurance plans may look similar on the surface. But when you dig into the plan details, you may discover some important differences that impact the coverage and services expected!
The following checklist may be helpful as you evaluate dental plan proposals:
1. Location of Procedures. In which category do typical procedures fall? Most carriers move procedures into different categories, such as X-rays, endodontics (root canals), periodontics (gum disease treatment) or oral surgery. If you are working with a Participating Provider Organization (PPO), it is crucial to know whether these procedures are classified as preventive, basic or major, as this will impact rates and out-of-pocket costs for employees and their family members.
2. Deductibles and Maximums. If the plan has a deductible, when does it apply and what is the amount? Is there a maximum amount that can be charged per family? What is the annual benefit maximum available per year? If orthodontia is included, what is the lifetime benefit available?
3. Coinsurance and Copayments. What is the coverage in- and out-of-network? For PPO plans, know what percent the plan pays by procedure category, typically stated as preventive, basic or major. For DHMO plans, it is important to know the member cost for common procedures.
4. U & C Allowances. What “Usual and Customary” allowance is used for out-of-network providers? Not all 90th percentiles are created equal. The 80th percentile for one carrier may equal the 90th for another. Know how the carriers compare, the source of their U&C data, and how often they update their records.
5. Frequency Limitations. How often can each type of X-ray be taken? How many cleanings are permitted per year? How many years are allowed between crown replacements? For example, one carrier may approve replacement of crowns every five years, while another may extend the limit to 10 years. You need to know these details for each plan under consideration.
6. Waiting Periods and Participation: What procedures require a waiting period before employees can access benefits? Is the policy different for current employees and new hires? What participation percentage of eligible employees does the carrier require?
7. Extra Benefit Services. Does the plan cover dental implants? What about composite fillings for molars? Does the orthodontia cover adults? Again, producers need to know this information.
8. Network Access. If the plan design includes a dental network, are there enough contracted providers close to the employer? Producers should know how the carrier counts the network providers, including the difference between access points, providers and locations.
9. Extended Value. Dental plans have come a long way in the last 10 years with innovative features, such as carry over maximums, sharing dollar maximums within the family and excluding preventive procedures from the maximum. Many plans also offer significant vision, hearing, Rx and other benefits packaged with the dental. Know what extra incentives are built into the plans that increase the value.
10. Commission. What commission is included in the plan quotes? Do not assume every carrier is quoting the same or that they are quoting what you requested. Find out.
After you compare the plan components, look at the rates for each plan. What is the value equation? If proposals miss the target you want for a client, ask carriers to revise the proposal to bring it in line with what you need.
When reviewing benefit proposals, what do you believe are the most important components? – Joe Deyo, Ameritas Group, State Manager in Nashville, Tenn., Group office