Understanding Your Dental Benefits
Table of Contents Foreword...2 Why Offer a Dental Benefit?...3 The Difference between Medical and Dental Needs and Treatments...3 Section 1. Things to Consider Before Selecting or Changing Your Dental Plan...4 Fully-Insured or Self-Insured Plan...5 Cost Sharing...6 Plan Administration...6 Who Should be Covered Under the Plan?...7 Section 2. Dental Benefit Plan Models...8 Fee-for-Service Dental Plans...8 Direct Reimbursement...8 Indemnity Plans...9 Managed Care Dental Plans... 10 Preferred Provider Organization (PPO)... 10 Dental Health Maintenance Organization (DHMO)/Capitation Plan/Pre-paid Plans... 10 Questions to Ask... 11 Other Types of Dental Plans... 12 Discount or Referral Dental Plans... 12 Point of Service Options... 12 Table or Schedule of Allowances Plans... 12 Section 3. Exclusions/Limitations and Cost Containment... 13 Pre-Existing Conditions... 13 UCR Three Different Concepts, Not One... 13 Annual Maximum... 14 Managed Care Cost Containment Measures... 14.. Least Expensive Alternative Treatment Provision... 14.. Claims Bundling... 14.. Dowcoding... 14.. Predetermination... 14 Section 4. Coordination of Benefits (COB)... 15 Types of COB... 15 Traditional... 15 Non-duplication COB... 15 Maintenance of Benefits... 15 Carve out... 15 Integration of Benefits... 15 Dependents... 16 When Does Secondary Pay?... 16 Section 5 Plan Analysis Service... 16 Glossary... 17 1
Foreword Since 1986, the ADA s Council on Dental Benefit Programs has offered free information to employers and benefits professionals about dental benefits options. This information is made available through the Council s Dental Benefit Information Service. This guide is intended to educate readers about the types of dental plans in the market, in order to help you determine which plan might be right for you and your company. It offers specific questions for you to ask before changing or selecting a new dental plan. It also will help you determine who to provide coverage for under your plan and how coordination of benefits should be determined. Finally, you will be encouraged to utilize the ADA s Plan Analysis Service, which provides a review of your current or proposed plan at no charge. If you have further questions, please contact your broker, benefits professional, state dental society or the Dental Benefit Information Service of the Council on Dental Benefit Programs directly at 800-621-8099. 2
Why Offer a Dental Benefit? Offering a dental benefits plan may make 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, work days lost can mean loss of income for employers. In addition to promoting oral health, a quality dental benefits plan can aid in the recruitment and retention of employees. In a competitive market, dental benefits are consistently cited as one of the most sought after employee benefits. The Difference between Medical and Dental Needs and Treatments Fortunately, offering a dental benefits plan to employees can be affordable. Due to the dental profession s promotion of fluoride, sealants and other preventive dental care, oral health in America has generally improved. According to data provided by the U.S. Department of Labor s Bureau of Labor Statistics, the cost of dental treatment has risen significantly less than the cost of medical treatment in the past few decades. In addition, dental needs and treatments differ from medical needs and treatments. The points below illustrate the differences between the two: MEDICAL NEEDS AND TREATMENTS CAN BE: Unpredictable Catastrophic High cost An insurable risk DENTAL NEEDS AND TREATMENTS ARE: Predictable Non-catastrophic Low cost Low risk As such, the design of a dental plan can differ from that of a medical plan. Dental disease is most often preventable and coverage is usually provided for those procedures which can prevent dental disease; dental treatment includes 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. 3
Section 1. Things to Consider Before Selecting or Changing Your Dental Plan Before selecting or changing a dental plan ask yourself the following questions: Will employees retain the freedom to choose the dentist they want? What type of routine dental care is covered? What major dental care is covered? How does the plan cover diagnostic and preventive services? Will it cover preventive services such as sealants and fluoride treatments, which may save patients money in the future? Will it provide for fullmouth x-rays? Does the plan cover routine dental care, like crowns, root canals, oral surgery and treatment of periodontal diseases? What major dental care is covered? Does the plan cover dentures, fixed bridges, implants or treatment for temporomandibular disorders? Does the plan cover orthodontic treatment? What limitations are there on age or multiple stage treatment? Is there a lifetime maximum? What limitations does the plan place on pre-existing conditions like missing teeth and existing prostheses? Will the plan allow for care by specialists? Is coverage limited to contracted specialists, or may patients see the specialist of their choice? How does the plan provide for emergency treatment? Is there coverage when a patient must see a non-contracted dentist after hours or while traveling? What proportion of the premium dollars paid by employers or beneficiaries goes to actual treatment? What proportion goes to administrative expenses? 4
Fully-Insured or Self-Insured Plan Should your company self-insure its dental plan or purchase a fully-insured plan? It s an important decision to make, as it can considerably affect benefit expenses and the company s available funds. Some things to take into consideration are the number of covered employees, the location of employees and the amount of risk the company is willing to assume. Fully-Insured Plans Fully-insured dental plans are typically business arrangements between an insurance company and an employer. Most plans are designed to pay only a portion of the patient s dental expenses. In a fully-insured plan the employer pays a monthly fixed premium to an insurance carrier. The insurance carrier assumes all of the risk associated with the claims of the employees, no matter how many claims are incurred. If there are any unused premiums dollars at the end of the plan year become assets of the insurance company and not the employer. In a fully-insured group plan, the insurance carrier agrees to provide coverage to the employees subject to various conditions. The carrier is responsible for all plan decisions and any legal actions are directed to the carrier. Self-Insured Plans In a self-insured plan, the employer generally has more flexibility. It can determine what dental expenses will be covered and also has responsibility for plan decisions. The employer pays its employees claims with its own money, as the claims are incurred. For those employers that do not want to process the claims themselves, they may choose to have an agreement with a third-party administrator (TPA), or an administrative services only (ASO) agreement with an insurance company to process the claims. However, in an ASO agreement the insurance company s standards and procedures will usually determine what benefits are covered, even though the plan is self-insured. A federal law known as the Employee Retirement Income Security Act of 1974 (ERISA) sets rules for most self-insured plans. ERISA plans are governed by the US Department of Labor and are exempt from state insurance laws. In summary, when deciding whether to self fund or fully insure a dental benefit plan, remember the following important points: Dental disease is preventable. Early detection and treatment of dental disease is most efficient and least costly. The need for dental care is universal and ongoing rather than episodic. The public s need for dental care is highly predictable. The dental needs of individuals within a specific group, however, may vary considerably. 5
Cost Sharing To control rising premiums for dental benefits, employers have looked for ways to share costs with their employees. One way of sharing costs, is to require employees to contribute towards the cost of their coverage. When the cost is shared by both the employer and the employee, the cost of the plan to the employer will be greatly reduced. Two ways that the cost of the plan can be shared between the employer and the employees are through premium contributions and through co-payments, co-insurance, deductibles and annual maximums. Premium Contributions: Insurance premiums are determined by the insurance company and regulated by the state. Usually insurance premiums are billed and paid on a monthly basis. Employers may require employees to share the cost of the plan premium. The employer will pay a portion of the premium and the employees may set aside pre-tax money to pay for the remaining premium through payroll deductions. A dental plan can also be a voluntary plan sponsored by the employer, but with the premiums paid 100% by the employee through payroll deductions. Any payment made by employees for their coverage in a self-insured dental plan can still be handled through payroll deductions. Instead of being sent to an insurance company for premiums, the contributions are held by the employer until claims are paid, or put in a tax-free trust that is controlled by the employer. Co-payments, Co-insurance and Deductibles: A co-payment, or co-pay as it is sometimes called, is a flat fee that the patient pays at the time of service. The fee is usually small, such as $10 or $15. Co-payments are common in capitation plans (e.g. DHMO), and less common in Preferred Provider Organization plans (PPOs). In many plans, patients must pay a portion of the services they receive. This payment is called co-insurance and is usually a small percentage of the service cost after the plan pays benefits. For example, if the plan pays 80 percent of the cost, the patient pays 20 percent of the cost. If the plan pays 90 percent, the patient pays 10 percent, and so forth. Co-insurance is common for PPO products and less common in DHMOs. A deductible is a flat amount that the employee must pay before they are eligible for certain benefits. The deductible may be an annual or a one-time charge. Generally, the greater the co-payment, co-insurance and deductibles are, the lower the premiums will be. Plan Administration The time and money you ll need to spend managing your plan is a cost that you will also need to consider. Plan administration usually includes adding and deleting employees, COBRA and HIPAA administration, and dealing with billing, eligibility and claims problems among other duties. A broker can provide many of these services. A broker can assist with claim issues and billing 6
problems, assist with late enrollees, handle conversion policies, report monthly claim experience and conduct new employee educational meetings. When working with a broker, be sure to discuss with him what administrative duties he ll assume, and which will remain your responsibility. Who Should be Covered Under the Plan? In addition to covering employees, most dental plans cover spouses and dependents as well. Some dental plans require that new employees work a minimum amount of time (for example, 30 days) before coverage begins. Although the employer generally has the right to determine which employees will be covered, if the plan is self funded, IRS rules limit the extent to which employees may be excluded because they are parttime, or have not reached a certain age or worked for a minimum period of time. In addition, most plans will terminate coverage of dependent children at a certain age; for example, at age 19 or upon completion of academic studies. And if the company has 20 or more employees, the federal law known as COBRA may require that employees or their dependents who would otherwise lose coverage be permitted to continue the coverage at their own expense for periods of up to 36 months. Even if the company has fewer than 20 employees, many states have similar laws. The ADA recognizes the importance of extending dental benefits to retirees and encourages plan purchasers to consider the continuation of dental coverage for retiring employees if it was offered in the past, or as an option for retirees to purchase at their own expense if it is not part of an employee retirement package. 7
Section 2. Dental Benefit Plan Models There are many ways to design a dental benefits plan. Although the individual features of plans may differ somewhat, the most common designs can be grouped into the following categories: Fee-for-Service dental plans are typically freedom-of-choice arrangements under which a dentist is paid for each service rendered according to the fees established by the dentist. Managed Care dental plans are health plans that integrate the financing and delivery of health care services to covered individuals by means of some or all of the following: arrangements with selected providers to furnish services to members; defined criteria for the selection of health care providers; financial incentives for members to use contracted providers; procedures associated with the plan, subject to limitations and exclusions. Fee-for-Service Plans Direct Reimbursement Benefits in this type of plan are based on dollars spent, rather than on the type of treatment. Direct Reimbursement is a self-funded plan that allows patients to go to the dentist of their choice. Depending on the plan, the patient pays the dentist directly (or the benefit can be directly assigned to the dental office) and then submits a paid receipt for proof of treatment. The administrator then reimburses the employee a percentage of the dental care costs. With some plans there are no insurance claim forms to complete and no administrative processing to be done by the dental office or an insurance company. DR is the ADA s preferred method of financing dental treatment. 8
The ADA, as well as state dental societies, brokers and benefits consultants can assist a company in estimating how different designs will affect costs. To request this assistance, you may contact the ADA s Council on Dental Benefit Programs at 800-621-8099. If you are considering a Direct Reimbursement dental plan, the following questions may be addressed: What co-payments and annual maximum should be established? Will the plan be administered in-house or by a third party? What records must be kept in order to comply with governmental regulations? What percentage of the cost will go toward administration? What safeguards and educational programs are in place to ensure that employees use their dental dollars wisely? What protection is available or offered to the employer if utilization is higher than expected in any given year? Indemnity Plans An indemnity dental plan is sometimes called traditional insurance. In this type of plan an insurance company pays claims based on the procedures performed, usually as a percentage of the charges. Generally an indemnity plan allows patients to choose their own dentists, but it may also be paired with a PPO. Most plans have a maximum allowance for each procedure they refer to as UCR or Usual, Customary or Reasonable fees. A common misperception is that the terms Usual, Customary and Reasonable are interchangeable; they are not. Dentists determine their own Usual or Reasonable fees. The insurance company s fee schedule is called Customary, but it may or may not reflect the fees that area dentists charge. Insurance companies usually do not disclose how their fee schedules are determined. Reimbursement is made according to the patient s plan of benefits, usually a percentage of the insurance company s fee schedule. If the plan purchaser is reviewing an indemnity dental plan with Customary fee schedule, answering the following questions may assist in the decision-making process: What data has been used to establish the fee schedule? Is the data source disclosed and is it easily accessible? How often are the fee levels updated? How are the updates communicated and to whom? At what percentile of the payer s Customary fee schedule is payment made? What percentage of the premiums is used for administration or non-claim payment costs and not for dental care? 9
Managed Care Dental Plans Preferred Provider Organization (PPO) A PPO plan is regular indemnity insurance combined with a network of dentists under contract to the insurance company to deliver specified services for set fees and according to the provisions of the contract. Contracted dentists must usually accept the fee schedule as dictated by the plan. Patients who see a non-contracted dentist may incur a greater out-of-pocket expense. When reviewing a PPO dental plan, answering the following questions may assist the plan purchaser in the decisionmaking process: What percentage of the premium is used for administration or nonclaim payment costs? Will the amount of the discount impact the patient s freedom to choose a non-participating dentist? How? Will the amount of the discount that the dentist is required to offer limit the number of treatment options for the plan s covered individuals? What possible liability might the employer face if the plan influences provider selection or treatment? What are the criteria for selection of providers for the plan? Does it have enough dentists under contract to adequately serve the group? What is the geographic distribution of patients to dentists? How often is this data updated and how is this communicated? Does it provide for specialist referrals? Are dentists limited to referring patients to contracted specialists? Are there restrictions or limitations on coverage if treatment is received by specialists? How does the program provide for emergency treatment? What provisions are in the program for emergency care away from home? Dental Health Maintenance Organization/Capitation Plan/ Pre-paid Plans A dental health maintenance organization (DHMO) is a common example of a capitation plan. Under a capitation plan, contracted dentists are pre-paid a certain amount each month for each patient that has designated or been assigned to that dentist. Dentists must then provide certain contracted services at no cost or reduced cost to those patients. The plan usually does not reimburse the dentist or patient for individual services and therefore patients must generally receive treatment at a contracted office in order to receive a benefit. 10
Questions to Ask If the plan purchaser is reviewing a DHMO or capitation plan, answering the following questions may assist in the decision-making process: What percentage of the premium is used for administration or non-claim payment costs? Is the employer provided with the necessary information to determine the amount of coverage as it relates to the treatment received by each member of the group? Does the plan distinguish the necessary treatment as determined by the treating dentist and the allowable coverage for the same? What is the utilization rate for patients with this type of coverage? 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? How current is this information or how often is this updated? What are the criteria for selecting dentists to participate in the program? What is the geographic distribution of patients to dentists? How often is this data updated? What is the ratio of dentists accepted to the program to those who applied to participate? What percentages of dentists participating in the program no longer accept new patients enrolled in the plan? How many dentists voluntarily withdrew from the program over the past two years, and why? 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? 11
Other Types of Dental Plans Discount or Referral Dental Plans Discount/referral plans are technically not insurance plans. The company selling the plan contracts with a network of dentists. Contracted dentists agree to discount their dental fees. Patients pay all the costs of treatment at the contracted rate determined by the plan. Point of Service Options Point of service options are arrangements in which patients with a managed care dental plan have the option of seeking treatment from an out-of-network provider. The reimbursement to the patient is usually based on a low table of allowances; with significantly reduced benefits than if the patient had selected an in-network provider. Table or Schedule of Allowances Plans These types of plans are indemnity plans that pay a set dollar amount for each procedure, irrespective of the actual charges. The patient is responsible for the difference between the carrier s payment and the charged fee. The plan may also be paired with a PPO that limits contracted dentists to a maximum allowable charge. If a plan calculates benefits according to a table of allowances, answering the following questions may assist the purchaser in the decisionmaking process: What is the difference between the fee schedule the payer calculates and a typical dentist s fee schedule for the listed procedures? What is the level of benefits? What provisions are in the plan for adjusting the table for inflation and changes in dental procedures? What provisions are in place for determining coverage for necessary procedures that are not included in the table? Is the terminology in the table consistent with the ADA s Current Dental Terminology manual? 12
Section 3. Exclusions/Limitations and Cost Containment Pre-Existing Conditions Some group health plans restrict coverage for dental conditions present before an individual s enrollment in the plan, such as missing teeth. These restrictions are known as pre-existing condition exclusions. If a plan imposes pre-existing condition exclusions, the length of the exclusion must be reduced by the amount of any prior creditable coverage. A certificate of creditable coverage will indicate the time the employee has been continuously covered under a plan and allows waiver of any waiting period to a pre-existing condition. Most coverage can be considered creditable coverage, including group dental coverage, COBRA continuation coverage, or coverage under an individual dental policy. If 63 days or more have passed without any coverage (called a break in coverage) a plan may not have to count the coverage before the break as creditable coverage. UCR Three Different Concepts, Not One Dental plans may use the terms Usual, Customary and Reasonable (UCR) to determine the portion of the dental treatment fee they are willing to pay for a particular procedure. As noted earlier the terms Usual, Customary and Reasonable are not interchangeable and UCR is a misleading acronym. Usual and Reasonable fees are determined by the dentist. An insurance company creates its own Customary fee schedule. There is no universally accepted method for determining the Customary fee schedule, which 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 lower than area dentists Usual or Reasonable fee for the same service. The benefit paid will generally be based on a percentage of the insurance company s Customary fee schedule. Patients often do not know what their out-of-pockets costs will be because third-party payers generally do not release their Customary fee schedule maximums to the public. 13
Annual Maximum Many dental plans feature a total annual maximum a maximum dollar amount that may be reimbursed each year, even if the patient s dental costs exceed that limit. A common annual maximum is $1,000 or $1,500, but it is not uncommon to see plans with much higher annual maximums of $2,000 or $3,000 to match the rising costs of dental treatment. These totals can be individual or family maximums. Managed Care Cost Containment Measures Cost containment measures are used throughout the healthcare industry and are used to determine the payment for services that have been provided. Health care plans should disclose information on how cost containment measures are used, or how they will affect the claim being considered. Any limitations, exclusions and applied cost containment measures should be described, and the application of deductibles, co-payments and co-insurance factors explained to the patients by the third-party payers and employers before the services are performed. Some of the most commonly used cost containment measures are: Least Expensive Alternative Treatment Provision (LEAT) A dental plan may not allow benefits for all treatment options. A Least Expensive Alternative Treatment Provision is a limitation found in many plans which reduces benefits to the least expensive of other possible treatment options as determined by the benefit plan, even when the dentist determines that a particular treatment is in your best interest. For example, the dentist may recommend a fixed bridge, but the plan may allow reimbursement only for a removable partial denture. The patient may not always understand the payer s least expensive treatment policy, and what the out of pocket costs are, until the explanation of benefits (EOB) is received. Claims Bundling Claims bundling is the systematic combining of distinct dental procedures by third-party payers that results in a reduced benefit for the patient/beneficiary. The ADA considers bundling of procedures to be potentially fraudulent. Downcoding Downcoding is a practice of third-party payers in which the benefits code has been changed to a less complex and/or lower cost procedure than was reported except where delineated in contract agreements. Predetermination Predetermination of benefits is an administrative procedure that may require the dentist to submit a treatment plan to the third party before treatment begins. The third party usually returns the treatment plan indicating one or more of the following: patient s eligibility, covered services, benefit amounts payable, application of appropriate deductibles, co-payment and/or maximum limitation. Under some programs, predetermination by the third party is required when covered charges are expected to exceed a certain amount. 14
Section 4. Coordination of Benefits (COB) Coordination of Benefits takes place when a patient is entitled to benefits from more than one dental plan. The plans will coordinate the benefits to eliminate over insurance or duplication of benefits. When both plans have COB provisions, the plan in which the patient is enrolled as an employee or as the main policyholder is primary. The plan in which the patient is enrolled as a dependent would be secondary. In addition, state laws and regulations often mandate coordination of benefits. Plan sponsors should be certain that the plan they select specifies its method for coordinating benefits with other plans. Types of COB Traditional - Traditional coordination of benefits allows the beneficiary to receive up to 100 percent of expenses from a combination of the primary and secondary plans. Non-duplication COB - In the case of non-duplication COB, if the primary carrier paid the same or more than what the secondary carrier would have paid if they had been primary, then the secondary carrier is not responsible for any payment at all. 15 Maintenance of Benefits - Maintenance of benefits (MOB) reduces covered charges by the amount the primary plan has paid, and then applies the plan deductible and co-insurance criteria. Consequently, the plan pays less than it would under a traditional COB arrangement, and the beneficiary is typically left with some cost sharing. Carve out - Carve out is a coordination method which first calculates the normal plan benefits that would be paid, then reduces this amount by the amount paid by the primary plan. Integration of Benefits - Integration of benefits means the sum of the total benefits paid by either carrier may satisfy the maximum of the secondary carrier. For example, if the secondary carrier has a plan year maximum of $1,500, and the client had a $3,000 bridge paid at 50% by the primary plan, the secondary carrier says it has satisfied its maximum for the entire plan year even though it was the primary carrier that paid the $1500.00. The secondary carrier hasn t paid anything, but it has satisfied its maximum.
Dependents Which policy pays first for dependents depends on the rules of the insurance company, or state laws. The typical rules for dependents of parents with overlapping coverage rely on the birthday rule, that is, the parent with the earliest birthday in a calendar year is primary. In the case of divorced/ separated parents, the court s decree would take precedence. When Does Secondary Pay? Usually, the secondary policy will not accept a claim until after the primary claim is paid, and then the secondary policy will often require a copy of that payment information (referred to as an EOB). More information about coordination of benefits can be received by contacting the ADA s Dental Benefit Information Service of the Council on Dental Benefit Programs at 800-621-8099. Section 5. Plan Analysis Service Still have questions about revising or changing your dental plan? The ADA s Plan Analysis Service is a benefit that the Dental Benefit Information Service (DBIS) of the Council on Dental Benefit Programs offers at no cost to groups offering dental benefits for the first time, or who wish to modify their current dental plan. The plan review will address the level and scope of coverage as well as benefits language. For more information, contact the DBIS of the Council on Dental Benefit Programs at 800-621-8099. 16
Conclusion About 170 million people have some form of dental insurance in the United States. Selecting a dental plan can be confusing. However, the more you know about dental benefits, the better equipped you will be to select the plan that s best for you or your employees. Don t be afraid to ask questions. Your insurance broker or dentist may be able to answer questions or provide more information on dental plans. The American Dental Association may also be a resource through its Dental Benefit Information Service of the Council on Dental Benefit Programs. Knowing the facts and having your questions answered before selecting a plan may avoid confusion and surprises when employees receive their explanation of benefits (EOB) and in some cases, a balance to their bill. Glossary For your quick reference, the terms relating to dental benefit plans that are used in this booklet are defined below. Contract Dentist - A dentist who agrees to provide specified services at specific levels of reimbursement under the terms and conditions stipulated by the contract. Contract Term - The period of time, usually 12 months, for which a contract is written. Deductible - The amount of a dental expense for which the beneficiary is responsible before a third party will assume any liability for payment of benefits. The deductible may be an annual or one-time charge, and may vary in amount from program to program. Eligibility Date - The date an individual and/or dependents become eligible for benefits under a dental benefits contract. This date is often referred to as the effective date. Exclusions - Dental services not covered under a dental benefit program. Fee-for-Service A method of reimbursement by which the dentist establishes and expects to receive his or her full fee for the specific service(s) performed. Fee Schedule - A list of the charges for specific dental procedures established or agreed to by a dentist. Flexible Spending Account (FSA) An employee reimbursement account primarily funded with employee-designated salary reductions. Funds are reimbursed to the employee for health care (medical and/or dental), dependent care, and/or legal expenses, and are considered a nontaxable benefit. Freedom of Choice - The concept that a patient has the right to choose any licensed dentist to deliver his or her oral health care without any type of coercion. 17
Managed Care A type of dental plan that is a contractual arrangement in which payment or reimbursement and/or utilization is controlled by a third party. This concept represents a cost containment system that directs the utilization of health care by: a) restricting the type, level and frequency of treatment; b) limiting the access to care; c) controlling the level of reimbursement for services; and d) controlling referrals to other dentists. Pre-authorization A statement by a third-party payer indicating that proposed treatment is covered under the terms of the benefit contract. Some plans require a dentist to submit a treatment plan to a third-party payer for approval before treatment is begun. Pre-certification Confirmation by a third-party payer of a patient s eligibility for coverage under a dental benefit program. Pre-determination A process used to determine the benefits available for dental services that are planned by the dentist: an estimate of the amounts payable by the plan if services are rendered when the patient is eligible. Under some programs, predetermination by the third party is required when covered charges are expected to exceed a certain amount. Premium - The regular (typically monthly) fee charged by third-party insurers and used to fund the dental plan. Reimbursement The payment made by a third party to a beneficiary, or to a dentist on behalf of the beneficiary, toward repayment of expenses incurred for dental services covered by the contractual arrangement. Self-funded plan - A program for providing employee benefits financed entirely through the employer, in place of purchasing such coverage from a commercial carrier. Third-Party Administrator (TPA) - An individual or company that processes and pays claims for self-funded dental plans. The TPA undertakes no financial risk for claims incurred. Third-Party Payer - Party to an insurance or prepayment agreement, usually an insurance company, prepayment plan, or government agency, responsible for paying the provider designated expenses incurred on behalf of the insured. Utilization - The extent to which the members of a covered group use a program over a stated period of time; specifically measured as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals. 18
Plan Analysis Service Still have questions about revising or changing your dental plan? The ADA s Dental Benefit Information Service of the Council on Dental Benefit Programs will review any current or proposed dental benefits plan for an employer or other group plan purchaser. These plan reviews address the level and scope of coverage as well as benefits language. If you would like to take advantage of the ADA s Plan Analysis Service, please have someone in your human resource department complete the form below and mail your current and/or proposed plans to the Service. Yes, I would like the American Dental Association to review the enclosed dental plan(s). I understand that there is no charge for this service. Name: Title: Company: Address: City, State, Zip: Phone: Number of employees: The attached dental plan(s) are current/proposed. Major questions or areas of concern about the plan(s): Please mail plan(s) and this form to: American Dental Association Council on Dental Benefit Programs Dental Benefit Information Service 211 East Chicago Avenue Chicago, IL 60611-2678 Or e-mail to dentalbenefits.org 19
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