Affordable Cosmetic Dentistry

The Advantages of Offering A Dental Benefits Plan

Dental health is a key factor to preserving one's general health. Employers and other plan sponsors offer dental benefits for a variety of reasons. Offering a dental benefits plan makes economic sense. A frequently overlooked reason for employee absences or poor work performance is dental disease or discomfort. And as every human resources professional knows, days lost can mean money lost. A quality dental benefits plan can aid in the recruitment and retention of employees. Dental benefits are consistently cited as one of the most sought after employee benefits.

Most medical needs and treatments are unpredictable, catastrophic, high cost and an insurable risk. Most dental needs and treatments are predictable, non-catastrophic, low cost and low risk. Dental disease is most often preventable; with the exception of damage due to an accident, dental treatment begins with relatively low-cost diagnostic procedures, such as exams and x-rays. If decay or disease is detected, the sooner it is treated, the less expensive that treatment will be. The dental needs of an employee group are highly predictable. For this reason, a dental benefits plan can often be self-funded. Extremes in cost and utilization (evident in many medical benefits) are rarely observed with dental statistics.

Selecting or Changing Your Dental Plan

Before selecting or changing a dental plan, there are some important things to consider. Some plans require patients to choose a dentist from a limited list of dentists. Choosing from a list is not the same thing as freedom of choice. If your dentist is not on such a list, don't hesitate to ask why he or she has elected not to participate.

Dental plans are typically business arrangements between an insurance company and an employer. Most plans are designed to pay only a portion of your dental expenses.

However, dental plans may exclude or discourage certain treatments, such as dental sealants, which can prevent tooth decay and save you money later on. Carefully read a plan and know its limitations. If a plan doesn't cover a procedure that is recommended by your dentist, this does not mean that the treatment isn't appropriate or needed.

Some plans do not cover pre-existing conditions, such as missing teeth. Others may not cover dental implants, specialist referrals and other dental needs. Even when you and your dentist agree on the appropriate treatment method for your condition, the contract provision of the dental plan may only pay a portion, or pay only for the least expensive alternative treatment (LEAT) as determined by the insurance company.

Dental plans may use the terms "usual, customary and reasonable" (UCR) to determine the portion of the dental treatment fee they will pay. UCR reimbursement levels are determined by different methods by the dental plan administrators. They may vary a great deal among plans - even when those plans operate in the same area. The fee the insurance company determines to be "customary" may be very low compared to the area's average professional fee for the same services. The plans then generally pay a certain percentage of the UCR level. The patient may then be required to pay a greater portion of the treatment costs.

Ask yourself the following questions before selecting a new plan:

• Will employees retain the freedom to choose their own dentists?
• Is the type of treatment determined by the patient and the dentist?
• Does the plan cover diagnostic, preventive and emergency services? Will it cover preventive services such as sealants and fluoride treatments, which may save patients money in the future? Will it provide for full-mouth x-rays?
• What type of routine dental care is covered? Does the plan cover crowns and bridges, braces, root canals, oral surgery and treatment of periodontal diseases?.
• What major dental care is covered? Does the plan cover dentures, implants or treatment for temporomandibular disorders?
• Will the plan allow for referrals to specialists? If so, will the dentist be limited to a list of specialists from which to choose?
• How does the plan provide for emergency treatment? What provisions are made for emergency care when you are away from home?
• If the plan requires monthly premiums, what percentage of that money goes to actual care and not to overhead or administration?

You and your dentist make the decision about treatment. While dental benefit coverage should be taken into consideration, it should not be the deciding factor in determining your choice of treatment.

Dental Health Maintenance Organization/Capitation PlanDental Health Maintenance Organization (DHMO) or capitation plans pay contracted dentists a fixed amount (usually on a monthly basis) per enrolled family or individual, regardless of utilization. In return, the dentists agree to provide specific types of treatment to the patient at no charge (for other treatments, a co-payment is required). Theoretically, the DHMO rewards dentists who keep patients in good health, thereby keeping costs low. DHMO models typically offer the least expensive dental plans.

If the plan purchaser is reviewing a DHMO or capitation plan, the following factors should be considered:

• What percentage of the premium is used for administration?
• Does the employer have access to sufficient information to determine the level and amount of treatment received by each member of the group?
• What is the utilization rate for patients in this program? What is the average waiting period for an initial appointment? What is the average period between appointments?
• What is the dentist/patient ratio for the program? What are the criteria for selecting dentists to participate in the program? What is the geographic distribution of patients to dentists?
• What is the ratio of dentists accepted to the program to those who applied to participate? How many dentists voluntarily withdrew from the program over the past two years?
• What is the capitated rate of compensation for the dentists? Is it sufficient compensation for the needs of the covered patient population? What provisions are made for dentists with unforeseen utilization or difficult cases?
• What are the benefits for patients requiring a specialist's care? How are specialists selected and compensated? Does the plan have adequate specialist participation?
• How does the program provide for emergency treatment? What provisions are in the program for emergency care away from home?

Dental Fee-for-Service Plans

Direct Reimbursement
Direct Reimbursement (DR) is a self-funded dental benefits plan that reimburses patients according to dollars spent on dental care, not type of treatment received. It allows the patient complete freedom to choose any dentist. Instead of paying monthly insurance premiums, even for employees who don't use the dentist, employers pay a percentage of actual treatments received. Moreover, employers are removed from the potential responsibility of influencing treatment decisions due to plan selection or sponsorship. DR is the ADA's preferred method of financing dental treatment

About Medicaid

• Medicaid is a joint and voluntary program between the federal government and the states, with the mission to provide health insurance coverage to the nation's poor, disabled and the impoverished elderly people. The federal government sets minimum eligibility standards and coverage requirements for Medicaid. Because Medicaid is an entitlement program, states choosing to participate must provide specified care to everyone who is eligible under guidelines developed by the federal government.
• Currently, a matching program is in place with the federal government using a formula measuring per capita income in each state relative to a national average. By law, matches must be at least 50 percent for medical assistance payments and normally cannot exceed 83 percent. Match rates for administrative costs run from 50 percent to 100 percent.

Medicaid is facing a funding crisis for the following reasons:

• Costs associated with the program (particularly prescription drug costs) continue to rise
• During more lucrative years, some states looked to Medicaid as a way to expand health coverage for the working poor and others without access to health insurance, expanding eligibility criteria.
• During economic downturns more individuals become eligible thereby increasing demands for funding and services.
• The growing population of people in need of long-term care.

Who is covered?

To qualify for Medicaid, an individual must meet financial criteria or may be a member of a group that is "categorically eligible" for the program, such as low-income children, pregnant women the elderly, people with disabilities and parents. Federal law mandates coverage of some groups below specified minimum income levels, but also gives states broad optional authority to extend Medicaid eligibility beyond these minimum standards. The flexibility that states have to establish their own eligibility rules has produced wide state-to-state variation in who and how many are covered by Medicaid.

What does Medicaid pay for?

Medicaid covers a broad range of services to meet the complex needs of the populations it serves, particularly the elderly and people with disabilities. Because Medicaid beneficiaries have limited financial resources, cost-sharing is limited and not permitted for children and pregnant women.

• State Medicaid programs must cover the following:
• Inpatient and outpatient hospital services
• Physician, midwife & certified nurse practitioner services
• Laboratory and x-ray fees
• Nursing home and home health care
• Early and periodic screening, diagnosis, and treatment (EPSDT) for children under 21
• Family planning
• Rural health clinics/federally qualified health centers

States have the authority to cover additional, optional services and receive federal matching funds.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Information

EPSDT services are required for the categorically qualified under age 21, but optional for medically needy (those who qualify as a result of high medical expenses that reduce income below a state's AFDC limit).

Required EPSDT Dental Services

Screening:
Screening services provided at intervals meeting reasonable dental standards, and at such other intervals to determine illness and which shall, at a minimum, include dental services that are provided at intervals meeting reasonable dental standards and at other intervals as medically necessary to determine the existence of illness, and which shall, at a minimum, include relief of pain and infections; restoration of teeth; and maintenance of dental health. Although an oral screening may be a part of a physical examination, it does not substitute for examination through direct referral to a dentist. A direct oral referral is required for every child in accordance with a state's periodicity schedule and at other intervals as medically necessary.

General care:
Dental care, at as early an age as necessary, needed for relief of pain, infections, restoration of teeth, and maintenance of dental health.

Emergency services:
Includes: services necessary to control bleeding, relieve pain, eliminate acute infection; operative procedures which are required to prevent pulpal death and the imminent loss of teeth; treatment of injuries to the teeth or supporting structures; palliative therapy for pericoronitis associated with impacted teeth.

Preventive Services:
Includes: instruction in self-care oral hygiene procedures; cleanings; sealants when appropriate to prevent pit and fissure caries.

Therapeutic Services:
Includes: pulp therapy for permanent and primary teeth; restoration of carious permanent and primary teeth with silver amalgam, silicate cement, plastic materials and stainless steel crowns; scalings and curettage; maintenance of space for posterior primary teeth lost permanently; and provision of removable prosthesis when masticatory function is impaired or when existing prosthesis is unserviceable; and orthodontic treatment when medically necessary to correct handicapping malocclusion.

Nursing Facilities:
Nursing facilities must provide routine dental services (to the extent they are covered under the state plan) and emergency dental services to meet the needs of each resident.

Additional Services

Any additional services provided are at the convenience of the state. To qualify as a state plan for medical assistance, the state plan must:

• Be uniformly applied to all political subdivisions of the state
• Provide for financial participation by the state equal to not less than 40 percent
• Provide a fair hearing for any individual whose claim is denied or not timely processed
• Provide for proper administration of the plan
• Designate a single state agency to administer the plan
• Submit reports to the Secretary of HHS as required
• Provide privacy safeguards for applicants
• Provide a fair opportunity for all individuals to apply
• Provide certain statutorily defined medical services, etc.

States may apply (and many have) for a federal waiver to make state-specific adjustments to many of these requirements. Check with your state for specific details.

About Medicare

The Centers for Medicare & Medicaid Services (CMS) administers Medicare, the nation's largest health insurance program, which covers nearly 40 million Americans. Medicare is a Health Insurance Program for people 65 years of age and older, some disabled people under 65 years of age, and people with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).

Medicare is a Health Insurance Program for:

• People 65 years of age and older.
• Some people with disabilities under age 65.
• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has Two Parts:

• Part A - Hospital Insurance - Most people do not have to pay for Part A.

Helps Pay For: Care in hospitals as an inpatient, critical access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas), skilled nursing facilities, hospice care, and some home health care.

Cost: Most people get Part A automatically when they turn age 65. They do not have to pay a monthly payment called a premium for Part A because they or a spouse paid Medicare taxes while they were working.

If you (or your spouse) did not pay Medicare taxes while you worked and you are age 65 or older, you still may be able to buy Part A. If you are not sure you have Part A, look on your red, white, and blue Medicare card. It will show "Hospital Part A" on the lower left corner of the card. You can also call the Social Security Administration toll free at 1-800-772-1213 or call your local Social Security office for more information about buying Part A. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772.

• Part B - Medical Insurance - Most people pay monthly for Part B.

Helps Pay For: Doctors' services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary

" The dental procedures we specialize in enhance our
patients' look and their quality of life! "

If you are a senior in the Lansing area or you have concerns about a relative's dental health, contact us today to schedule a consultation. It is critical to address questions and concerns early on to help avoid the onset of tooth loss and serious periodontal disease.